Welcome to our session. Today, I have the honor, I'm Alicia Barnes, I have the honor of introducing Dr. Sud on her talk, I Am In My Lane, Gun Violence, a Public Health Issue. A little bit about Dr. Sud. She is a senior professor for child mental health policy at BCUHS in Richmond, Virginia. She served as the co-chair on National Task Force for School Violence of ACAP in 2016. Governor Kaine actually appointed her as the mental health expert at the panel that investigated the Virginia Tech massacre of 2007. She got the Agnes Purcell McGavin Prevention Award from the American Psychiatric Association. Her interests also include violence prevention efforts related to firearms. And she edited three books on mental health policy and the prevention in children's mental health and children and social justice, which is of particular interest as a child psychiatrist. So with that, I welcome Dr. Sud, and thank you all for being here for this important topic. Thank you all for being the brave souls of hanging around here on Monday afternoon, I guess. It's a beautiful day out there. So the first one, I think, since the last two foggy days. So I appreciate your presence here. So as Ayesha introduced me, I'm an old lady now and work in Virginia Commonwealth University in Richmond for the last 34 years. I see one person who was there in the panel discussion earlier, so that's good. So by way of kind of introduction, because we always sort of have this kind of imposter syndrome, this is a particular area of our work which is really not central or kind of what we do for a living, right? So how I kind of came about into this was serendipity. Some of it was mid-career as I saw kids in my clinical practice. And I would see an eight-year-old or a six-year-old terribly anxious and or very aggressive. There was one kid I remember who had a terrible ADHD and he was a kid that the inpatient folks were really frightened of because he'd come in and he'd be highly aggressive. And after about four or five sessions of getting comfortable with me as his outpatient provider, he suddenly began to crawl on the floor and said, I'm scared. And this was not sort of a sentence I would hear out of this kid. And then he revealed to me how he had watched literally on a weekly basis, if you can believe it, seeing bodies on his front stoop lying in a pool of blood. And I said to myself, and at that time, I was, I think, in my late 40s, early 50s, and I said to myself, you know, I haven't seen a dead body in my life in front of me, secondary to intentional or unintentional injuries. And here is this kid who's so young who is kind of experiencing this in such a short period of his life. And to me, that became really a travesty. And the second thing came about with the Virginia Tech shooting and me being appointed on the governor's panel for as the mental health expert. All of a sudden, firearms kind of got thrust in my vision in a way which I had not anticipated. And I began to kind of think about it. And clearly, this is one of the most polarizing areas in our work. Because as soon as the word comes out about firearm violence, it's a very polarizing sort of notion because people begin to think about the Second Amendment and so on and so forth. And so over years, over the last decade, I have really tried to kind of change sort of the conversation into sort of this notion of safety and making sure that the dialogue is about safety. Because I think all human beings want others to be safe. And how can we have that conversation and also begin to focus on really legitimizing our role as providers who do consider firearm violence very much within our purview because it has a major impact. And I'll try to make a case of that as we kind of go along. So having said that, these are my disclosures here. And let's kind of move on and talk about what we're going to cover today. So we will be looking at the epidemiology of gun violence and be able to frame this in a public health perspective. And in a public health perspective, you kind of go back to medical school training. There are certain elements which I will cover. And then also understand the historical perspective of why gun-related issues are such a problem for our country. And then outline our role as potential roles as health care providers in this work that we continue to do. So let's just define what firearm injury is. And this is a gunshot wound or penetrating injury from a weapon that uses powder charged to fire projectile. And so it doesn't pertain to things like gas-powered guns or BB guns or pellet guns because they don't use powder charge as a projectile. So just by way of definition, although this is probably an academic issue here. Type of injuries that we see are intentional self-injury, which is suicide, self-injurious behaviors, unintentional, where you're caught in the crossfire, interpersonal, where there are problems within two people and so it gets resolved by firearm-related violence, legal intervention, where our police force or other law enforcement individuals kind of interact with an individual and there is the tragedy that occurs of losing life. And then obviously, some stuff you just can't kind of put into any particular bucket there. And then the notion of defensive gun use, which a lot of people will talk about. We really have no data to say what is the data on it. It's just something that kind of gets thrown around and we kind of move along. Let's take a little bit, a look at the epidemiology. And these are frightening statistics which show that homicide rates, this is the 2021 data from the CDC, which indicates how homicides have increased significantly in the past couple of years, particularly since the pandemic. Suicide rates have gone up. I mean, they still remain high. They're 10% increase, but homicides are profoundly increased. And when we look at the demographics, what we find is that particularly in the homicides, it is the black male who has shown the greatest increase in homicides rates. Suicides have kind of sort of also gone up, but it's mostly in the arena of American Indians and Alaskan natives that you see this type of data. So in summary, between 2019 and 2020, the firearm homicide rates have increased about 35%. Firearm suicide rates remain high, although they haven't exponentially increased as much as the homicide. And the largest increase in firearms were among black people, 39%. And the largest increase in firearm suicides were among American Indians. So that's the summative kind of portion of this epidemiology. Then let's take a look at poverty and how it is connected. So we have some data on poverty. And what we find is that it is inversely related to the wealth in a particular place. All the suicides do not seem to be connected to what poverty looks like within a community. So here, the summary is that poverty confers five times higher risk for being involved in homicides. And as this shows that the counties with the highest poverty level had firearm homicide rates 4.5 times as high and firearm suicide rates 1.3 times as high as counties with the lowest poverty level. And so it certainly is the social determinants of health which really impact some of this epidemiology here. And the firearm homicide rate is at an all time, 25 years, this is the highest rate that we see in our country. Let's take a look at what is the data, the most recent one from 2017, which kind of talks about intentional versus unintentional and so on and so forth. And I think for us, mostly the unintentional one is the one that can be prevented in some ways, although the others can be prevented too. So this data is kind of important. And more important than that is what we all kind of really looking at the economic cost of violence. This goes in billions. And these things I have kind of highlighted in red is our lane, which is where from a medical perspective, there's a huge amount of investment we make because if a person dies, obviously then you look at PTSD and counseling and all of the other elements, whereas if the person goes into rehab, there's a whole bunch of stuff that goes into medical care, mental health care, and ambulance and patient transport. So when we were told to be in our lane by the NRA, that was something that began to be looked at. And we find the tremendous economic cost aside from the other cost to humanity. So this data is really powerful in kind of saying, this is not something that the country can afford. The data on the right is Virginia data, where I come from. And as you can see, how much every taxpayer is paying, the bottom line. So it's coming out of someone's wallet and is certainly one of us. So in summary regarding the epidemiology, this is the statistic. And these are quite horrifying in some ways. And so just to kind of take home, this is too much of information for you to kind of put in a memory bank, but it's certainly something that you cannot ignore, you cannot sneeze at. So let me kind of now go into clinical work, which is the work that I do and which really is my sort of daily stuff that I do in this, in my regular outpatient clinic, as well as the work that I do with the juvenile justice system. And those are not mentioned here, but these are some of the examples. So this is a seven-year-old, stable regular follow-up for ADHD, visibly shaking, anxious, withdrawn, and had just attended the funeral of a five-year-old cousin who had accidentally shot himself. Yeah, basically he found the gun, the uncle had left it and it was loaded and the safety lock was not on. And that is how this kid ended up and the kid then spent the session talking about, he was very circumspect about it, but I could see how profoundly it had impacted this kid. 10-year-old with significant family turmoil, witness to domestic violence and neglect. And this girl had been very, very quiet in her sessions with me. I could see that she was very involuted and withdrawn, goes to a friend's home and while they're playing, you know, hide and go seek in the home, she finds this friend's, I think, parent's gun lying on the shelf. She was disturbed herself. She was very depressed. So she takes the gun and, you know, basically pulls the trigger. Fortunately, it wasn't loaded. The friend tells the mother, she ends up in the emergency room and fortunately this tragedy was avoided. The girl was taken out of custody of the mother because there was a lot of problems which were unearthed as a result of it. But this kind of stuff, it's kind of sad to see that young kids like this are exposed to it. The last one, because of interest of time, you know, eight-year-old referred for the management of post-traumatic stress disorder. She came to me about six months after this incident. She had gone to her grandma's home and while she was sleeping at 4 a.m., a bullet went through the siding of the house, which was not intended for that home, but it was an accidental shooting and it grazed her scalp and she ended up having surgeries for the same and was obviously then suffering from the PTSD for which she came to me because she was having horrific nightmares about it six months down the road and continued to be very symptomatic as you can long. So this is a kid who was just like caught in the crossfire, had no reason at sitting, you know, sleeping in her grandma's home, why should this be happening? But this stuff is rife. I see this on a weekly basis. Again, I practice in an urban inner city area. Nevertheless, most of you have, are also probably privy to some of this that you see. So what does this kind of do to kids? So the available research shows that exposure to gun violence is perhaps even more traumatizing than experiencing sort of this broad spectrum of other natural and human generated disasters. It's still a science and it's still sort of an area or topic which has not really been looked at very well, but the studies that we have up here kind of tell us that it's certainly the incidence of these things, probably because of social media, because of what we see, but definitely there has been a spike in the number of these incidents that kids are exposed to. And so we really need to start documenting very well, even case reports of these so that we can start, begin to make cases, but we are beginning to, I actually wrote an article on the impact of mass shooting on kids. So as the data and the research and information about this sort of develops, we are going to be in a better position to make a case for these. But some of the literature does talk about the developmental differences with younger kids having more of a nonspecific type of anxiety that you see, and these kids tend to get very regressed. They have sadness, crying. They usually can't kind of identify what's making them. And you've probably always heard of how if, like I'm in academics, and each time some incident like this occurs, my media folks will call me and say, how do you speak to kids about this? And so this has become like almost like a thing, a road for me to kind of talk about what to do with kids' anxiety. And I feel really helpless in not knowing exactly what is sort of the path you try to do the best you can. On the other hand, adolescents, as they grow older, they develop more classic post-traumatic stress disorder type of behavior. But the big problem here is the notion of the opposite, which is delinquency and the identification with the aggressor that we see many times with traumatized kids, that they go on to become much more violent than you would expect someone who had been exposed to this. And you see that a lot in the juvenile justice population that I see. And then the other sort of bad kind of byproduct of this is that repeated trauma does lead to, as we all know, sort of the numbness that comes with trauma and severe psychic numbing. And eventually what ends up happening is that they adapt to the events that are there and finally decide that I just can't deal with this any longer. And so they disconnect from it. And what it leads to is this notion of that there's compassion fatigue. They can no longer. So they disconnect from a psychodynamic perspective that makes perfect sense. That if it's happening too often, you just don't have the emotional padding to take that. And so the direct result of this is oftentimes when these kids are talking about these things, affectively they're very constricted and restricted. And so that's a very unfortunate thing because they become much more prone to act in an aggressive way when they are threatened. And that's the genesis of how this comes about. It's sort of the identification with the aggressor notion and that it breeds kind of violence. So as we look at it in kids, what we see is a whole bunch of depression, anxiety, PTSD, which may not be prevalent in all of them, but because children do have a great degree of resilience and some of them grow up to be kind of fine. But if there is what we quote, Lenorter talks about type two trauma, where there's a repeated event, repeated again and again and again, it leads to results which are very different and also the conduct disorder and aggression pieces of it. Now, it is very important to kind of know although we look at gun violence as the ultimate event or the penultimate event, there's really a whole lot of bunch of stuff that goes on, which I like to focus on because otherwise it leaves you in a sense of helplessness, learned helplessness as providers. But there are some things that we can do. Before I move on to some of those things, let's talk about what are social determinants of health. And as some of you may know, the WHO talks about 90% of healthcare outcomes being dependent upon social determinants of health. And these are things like food, these are things like housing, transportation, this has to do with food insecurity, those kinds of things, which we don't really do much with. We usually see people when they come to us for tertiary care purposes, but our lives are very much connected to these things where we need to become much more involved in becoming more vocal advocates, although that's not our lane, but it is an important one that impacts the healthcare outcomes of individuals. So we need to be familiar with what these things are. So these are things like individuals who we work with, what degree of investment and respect and feeling of trust that they have in institutions. It could be the police force, it could be council members, it could be people who kind of make policies around where the grocery store is going to be, those kinds of things. The notion of who decided that my school is not going to have air conditioning or my school is not going to have heating in the winter, those kinds of things. The person's capability, inherent capability of knowing that there is something that they can look forward to as far as social mobility, the ability to kind of move up within that. Income, equality, it could be gender, it could be ethnicity, race, et cetera. And we talk a lot about racism, which is kind of sort of embedded within the structures of a society. And until we don't begin to take a look at that, if you read the book, what is called The Uneven Ladder or something like that, there's a beautiful book, it's a slim volume, and really talks about the haves and the have-nots. And the more of the difference between those two leads to very bad health outcomes for particular communities. So there's data to kind of show that when you have this big discrepancy and difference in some of the social determinants of health, the outcomes for society is not good, including the exposure to firearm violence. So these have, what we have found after the pandemic is because perhaps there have been, schools not been around, virtual schooling, loss of the social fabric and the structure that kids have experienced, the stresses that have been there, the isolation, all of those have really impacted young kids, particularly those who come from backgrounds in where the social determinants of health are profoundly sort of weighted in some ways. So this is a study which was done looking at census tracts and looking at levels of poverty within these areas where they connected and studied the rate of firearm homicides and violence. So it's a busy slide, but I just want to kind of show that they compared mass shootings versus the non-mass shootings in these counties. And what they found was that there was a profound and robust relationship between parameters of social determinants of health and rates of firearm violence. So this is the first study which has looked at actually the connection between poverty and what it does to the rates of firearm violence. With every one standard deviation of increase in poverty and males living alone linked to 26% and 17% higher homicide rates. This is kind of really telling and this is a very recent study which has looked at it. So I'm not going to repeat this, but it's the same sort of notion of the rich-poor gap which translates into these types of events in a particular community. And that we do know now this is one of those risk factors which needs to be addressed if we are looking at things like societal re-engineering. So that concept of societal re-engineering in which we can play a small part, but having that knowledge allows us to be good advocates in a voice. This study, again, has to do with social determinants of health and actually looked at the English language achievement and math scores in children who were living in high homicide school catchment areas. And what they found was that there was a profound reduction in the achievement in both these areas in kids who lived in high homicide areas versus those in comparison to other areas. So this is some of the data. So having given you the epidemiology of this thing which is very important, I want to make an argument that the gun violence as sort of an area, a topic is really center stage to healthcare. We talked about the economic costs, we talked about what happens to kids from a clinical perspective. And this is your and my work and it's certainly our lane. So no one can tell us why and I'll give you some more data to kind of bolster this argument. And this is the idea of this talk is not to be a polarizing one because I very quickly realized that as soon as you begin to start talking about guns being sort of the reason, you've lost the conversation because people stop listening to you. And as healthcare providers, we very well know that we want people to listen to us. So you have to find the common ground which allows people to come together on this subject. And really what I find is that the issue that we need to focus on is safety. And how do we keep people safe irrespective of whether you own a gun or you don't own a gun. And we'll talk about some specific strategies of how to do that. So I'm making a case for all of you that we have to approach this from a public health perspective and go back to some of the lessons we learned when we trained as we go along. So our role as healthcare providers, just to, if you don't actually know it, you're probably very familiar with it, is that we see people when they're very sick, right? We see them always in a tertiary care setting. Very few of us are in primary prevention unless that's your sort of side interest. that's not what we are trained as clinicians to do. And secondary prevention, unless you work in school mental health, for example, where you look at high risk kids and you kind of intervene. But generally speaking, our world is made up of tertiary intervention. And when we look at shootings, what we find is that our interventions paradigms are very undeveloped. And I'll make a case for that. That when you have a shooting, it either ends up in the person dying, and they go to the morgue, or you resuscitate them, and then they kind of get better, and then you send them out in the community, and then you know nothing about it. That's it. But what we know now is that, and we need to be very aware of it, and keenly aware of it, that this really kind of ignores the secondary morbidity that goes along with the shooting. So there is the person who kind of saw and witnessed that event, there's the friend of the person, and I won't go through all of it, but there is data to show that for every one homicide, there are 137 people impacted by it. That is huge. So it's not just that event. I always think of it as that when someone dies, it's like the entire history, the entire how they grew up, what investment was put into them by different people, all just that goes down a hole. And so the impact of it is quite profound. And then you have them that goes on, but then also us. These are the surgical ICU nurses, these are the people who are kind of managing these folks in the emergency room, and they're also vicariously kind of going through the same issues that I talked about the kids, which is sort of this disconnect, that I can't really deal with this, so I'm going to just disconnect, which then leads to trauma of its own kind. And we see so much of burnout and so much of problems that people don't like to talk about, but it gets transferred into our lives and into our work. So gun violence is tremendously, profoundly impactful, and when this youth goes back into the community, the whole retaliation, revenge begins, right? So that's another big problem, which is where hospital prevention programs are so helpful. Those have been shown to be quite effective in managing some of the stopping of the retaliatory violence that goes on. So we have to kind of understand where all of these things are coming from as far as risk factors and protective factors. And so, again, this kind of illustrates that, and then makes the case that we don't want to get to the point where the shooting is occurring, and then you see the morbidity and mortality from that, but you really want to kind of intervene at a societal level at some of the expressions of the risk factors, and then how can we kind of prevent them from escalating to the point where it ends up in a disastrous sort of outcome. So having given you the background, now I'm going to get into the meat of what I was trying to kind of point out, which is this beautiful diagram, which kind of is, again, a revision of what a public health approach means. So whenever we talk about a public health approach, we are kind of looking at first knowing exactly the scope of the problem, which we made a big case for, right? We know that the epidemiology certainly makes a case that this is really an escalating problem. It's going nowhere, and it is getting worse by the day. And we know who are these individuals who get impacted. We know them from ethnicity, gender. We know who are the people in whom suicides versus homicides are more there, although I don't show you that thing, but generally out of that entire pie of firearm-related fatalities, suicides outnumber the homicides, but the homicides garner a great deal of attention. So we know that. The second is to identify what are the risk and protective factors, because in a public health approach, you want to really enhance those protective factors and reduce those risk factors. The third piece of it is the notion of finding intervention strategies that are helpful, that are effective, that are evidence-based. And the whole point of that is that when you put those interventions into place, you put on top of it research designs, which look at, is this intervention really effective? And if it's not effective, you go back again to the thing back again and find out what is a good intervention problem. And the public health approach sort of self-cleans itself, and we get better and better as we go along. So where you want to get involved in all of this is up to you, but we have to start looking at gun violence from that perspective. So let me go back to the scope of the problem. We definitely know that this is a problem. It is the method used in half of all suicide deaths. More than half of female intimate partner homicides are committed by firearms, and there's a slide which kind of goes into details about it. And that we definitely know that young kids are very, very affected by this, and we know the data on it. The CDC picks up that information and provides it on a public platform. So it's there to be kind of found that this is profoundly. So who are the people at risk? These are the individuals who have had a history of suicide attempt or ideation with continued access to a gun. So that is sort of the most important piece there, with access to a gun. So we know that 20% of adolescents can have passive suicidal ideations or suicidal ideations, but only 2% attempt them. And these are the kids who are at risk. Similarly with adults, that there are certain people. History of assault by a peer and are using the gun for protection. Those experiencing partner violence, and again, very, very strong capacity for that event to go forward. History of alcohol and substance abuse. And this is where the mental health piece, where you have a mental illness which is connected to past aggressive behaviors as well as alcohol and substance abuse. These are the people at higher risk for perpetrating and being victims. And certainly kids who have access to unlocked guns and have had a history of suicide attempts, that these put them at risk. So risk factors again, access to firearms, access to a firearm in one's home doubles one's chance of dying by homicide and increases likelihood of suicide death more than fivefold. So you can imagine what risk having this gun in people who are at risk. And history of violent behavior, exposure to violence, risky alcohol. I had a kid come in sometime in February for a new patient evaluation. This was a stepmother who brought the kid in and I recall distinctly the presenting problem was aggression, terrible aggression for which she could no longer kind of handle it. And so I always ask about, begin my conversation with a strength-based approach, what do you like, blah, blah, blah. Christmas has just sort of come, what did you get for a present? And he got a BB gun. And so I just kind of tucked it behind in my head and then 30th minute, 40th minute after I had built a rapport with the stepmother, she had no concept that aggressive kid to give them a BB gun and to kind of encourage that type of a thing was not the best present. Whereas a BB gun with another kid who didn't have a history like that was perfectly fine, right? People use guns. I remember coming to this country and not allowing my kids to play with a plastic gun and I had to quickly change my ways and by age six they were getting exactly what their peers were getting. So you can't be puritanical about it, but you have to know which are the kids at risk. And so I spent a great deal of time, 15 minutes of my time, just going over what does that do to your child who you're worried about as far as aggression, that you're kind of sort of creating the situation where the kid sees violence as an option. So there are things like this that go on. Okay, so this is step two, which is identifying risk and protective factors. Then we look at developing and evaluating interventions and these interventions have to do with the database, which we're gradually beginning to develop. And some of these interventions are things like domestic violence prohibition, where someone has threatened a partner and that gun gets sort of taken away or removed. Second is extreme risk laws, which are the ERP laws, red flag laws. You may have heard of them. And there are now 23 states which have actually have made these laws the laws of the state. So we are kind of getting there. We still have many states that don't have it, but these are some terrific interventions and I'll show you the data on that. Access to lethal means reduced by removing guns from the home or storing the guns in a safe way where there's no ammunition in the gun or they have safety locks. And these things are becoming more common in that as these guns are given out to people, that there are a lot of giveaways in the way of safety locks and storage. So these have been shown to reduce the morbidity from gun violence tremendously. And these are very low hanging fruit, which we need to really sort of enact in our conversations with families and so on and so forth. So these are some of the interventions that as this data is developing and this information is developing, these are some of our tools that are there, which are shown to be effective. So these interventions interrupt the cycle of violence and connect the highest risk individuals to a variety of social services as we go along. So let me talk a little bit about the ERP laws, and sorry, just tell you about the ERP laws and we'll go into it a little later. So from a data perspective, we have, certainly everyone asks about the notion of gun violence and mental health. And the general bottom line of all of this is that mental health does not confer a greater risk, although 3% of all gun deaths are attributable to serious mental illness, but usually these are the individuals who have either had a history of a violent past or are engaged in concurrent comorbid substance abuse that is a variable there. So you have to kind of know that this confers a higher risk. But mental health by itself is not a risk factor which, and it's a very important concept to grasp because usually that's what the folks kind of turn to, that there's something, this is mental illness which has caused this. And so this data is very important for you as a practitioner, otherwise it further stigmatizes sort of the notion of seeking help for mental health reasons. And we definitely know that all individuals with mental illness are not more prone to this. So now I'll kind of talk about this concept of what is called ASK, which is Asking Saves Kids. So this is, I'm a child psychiatrist, so that's my background, but we've got to sort of look at some of this. This data is very important to know that one in three homes have got an unlocked gun at home, and that three in four of these kids who are living in these homes know where that gun is. And it's very interesting because when I do clinical interviews with people and I ask the mother, does the kid know that? And the kid pipes up and says, I know exactly where it is. And it's very interesting how parents kind of view the thing and how the child views things. So it's very important to ask direct questions regarding it because the statistics are kind of staggering. It's the number two killer for children in the country. And we also know that, look at this flip statistic that suicides attempted by firearms, 90% success rate. But if you do, if suicide attempts with a non-firearm method, the fatality is 10%. So you can see how important this statistic is in really raising your awareness that this is something that I can prevent. I can kind of stop this from moving forward. Now this is the slide that I was kind of referencing, which is the intersection between guns and domestic violence and intimate partner violence is a huge public health hazard. Nearly half of women killed in the US are murdered by a current or former intimate partner. And there are about 4.5 million women in the US who have been threatened with a gun and nearly 1 million of these who have been shot and shot by an intimate partner. So there's this sort of, there's this bell ringing in the back when intimate partner violence is occurring that you need to kind of sit up and pay attention and do everything in your power to kind of make sure that this becomes sort of a thing that you need to address in your work. So over half of intimate partner homicides are committed with a gun and a woman is five times more likely to be murdered when her abuser has access to a gun. So that's again where the gun sort of comes in because it's so fast, it's so quick, it's an impulsive thing, and that's where the ERPO laws come into play. So that's the intervention, which is useful with that. And knowledge of it is very important whichever state you are. Violence kind of sort of continues over the lifespan and you can see that right from, and they're all kind of interconnected. And victims of one form of violence are likely to experience another form. So the young toddler who's kind of violent in the recess or in the playground and you go on and the ostracizing of the kid as that occurs and you kind of go on to how you treat other people in your social kind of circle and so on and so forth. So you can see that this trajectory really continues on throughout life. So for me as a child psychiatrist, the genesis of the violence began very early and it begins with things like trauma, exposure to trauma, victimization, because this leads to the kid becoming an abuser. The victims end up becoming the abusers. So it kind of starts off very early and this is how they treat others. So a quick word on the state of gun violence prevention research. As you're probably very aware that the Dickey Amendment was the one which kind of put the kibosh on the CDC doing any type of research in this area. And this happened after the JAMA published a study which talked about the notion, this was in 1993, gun ownership is a risk factor for homicides in the home. At that point in time, CDC was conducting research in this area and that led to the Dickey Amendment. And basically they lobbied the NRA and everyone sort of came after the CDC and said that if any money goes to the CDC for research around injury from firearms, they're going to remove $1.6 million from the funding for the CDC. And that led to the CDC saying, okay, we're not going to do this. And that led to the 2.6 million from the CDC. That was quite a sum then, right? So it stopped and this was the Dickey Amendment. None of the funds made available for injury prevention and control, the CDC may be used to advocate or promote gun control. And so what that led to was this hiatus of information. And when you don't have information and you don't have data, you don't get funding for anything, right? So there's this big, huge thing. Till recently, and as you can see here, this is him with the director in 2012. He authored an opinion piece where he says, we won't know the cause of gun violence until we look for it. And so he completely changed his sort of thoughts on it and said this was a mistake to do this with the CDC. And basically his notion was, and he wrote this opinion piece, he wrote a letter to Mike Thompson asking for the Dickey Amendment to be repealed. Research could have continued on in gun violence without infringing on the rights of gun owners in the same fashion that the highway industry continued this research without eliminating the automobile, right? So this is where the motor vehicle accidents and the seatbelt laws and all of those came around. So I just want to give you a kernel of hope here, that there is hope. We have got to start little by little by little by little by little and build on it and not get, because even in my state, I have seen a tremendous improvement and a progressive change because people continue to advocate for the right things. So we have come now to the point where we still are very low as far as the funding for research goes, but there are many private arenas where research in this area is going. And these are nonprofit foundations, private foundations which have provided money for all of this. There was a study done in 2013, not study, it was a panel which was pulled together by these two folks who kind of talked about putting in money to institute laws which reinforce the notion of background checks on firearm possession, definition of expanding the definition of who are high-risk individuals, federal restrictions on persons with mental health history but with violence, so previous history of violence, trafficking and dealer licensing penalties, meaning those folks who are selling guns without appropriate licenses should have penalties put into place so that they actually sit up and pay attention. Childproofing, which is the safe storage, whole notion of putting safety locks, those kinds of things. Assault weapons and high-capacity magazine bans, and then looking at adequately funding our institutions which conduct this research so that we know what we are doing and we are just not pulling stuff from out there. Most recently, I kind of saw this, which is the Public Health Research into Firearm Mobility and Mortality, just came out, where multiple health organizations, including the APA, has urged Congress to provide $35 million for CDC, $25 million to the NIH, and $1 million to National Institutes of Justice to actually work in this particular arena and really push for the funding. So we're kind of sort of coming around in actually funding this stuff, so that's your funding kind of scope. So we are at a better place than we were about seven years ago, eight years ago. So an ounce of prevention is better than a pound of cure, and so let's move into our role as healthcare providers. Now, this is a slide which kind of shows that when we ask about smoking, so for example, we see smoking as a big public health hazard, that all practitioners do ask about it, and many of us actually ask about it. Similarly for falls and for physical wellness and not being in danger at home, this has become a question that all healthcare providers ask. But we don't ask about community violence. We don't ask about, that's not sort of a contemporary way of kind of asking the kids that we see or the adults that we see, that are they exposed to community violence? Many of these individuals, when you ask them directly, will tell you that they're listening to gunshots in the neighborhood is a common way of growing up. And so that puts them at great risk and you have to know how to do to mitigate that. So as you can see, this problem is not just the problem of the individual, but it is really a Venn diagram which kind of is a socio-ecological model that we have to kind of look at. Now when you look at it, you kind of say, where do I fit in? How am I going to even manage this? But we can all have sort of pieces of that portion of where you want to get involved. So for example, I do my tertiary work, but I also think in terms of prevention, but there is in urban inner city Richmond, there's the East End, where I get involved in community programs, where I feel like I'm not in my own lane, but I inform sort of the process by evaluating kids, allowing them fast access to my clinics, but also looking at primary prevention, identifying kids at risk, seeing what we can do, really helping the notion of infusing the community with resources such as connecting kids to access to programs such as like the symphony or getting a person who can donate bikes to the place or they are engaged in sports, starting up a league, those kinds of things, where you're looking at the development of the neighborhood as the ecological kind of environment within the kid where the kid is living so that they don't get kind of involved in all of those things. So there are different aspects of the socio-ecological model where someone can get used to. But let me kind of stop that and talk about your role as an individual practitioner. It's very important to kind of assess where they, whether directly asking them about sort of issues which have to do with mental health, such as depression, being suicidal. Is there any sort of possibility that they have been exposed to any type of violence? Have they been victims of assaults? And what is their relationship with their parents, et cetera? So this becomes kind of an important thing. Now once you identify that there is a firearm within the home, at that point, the kind of questions that you can ask of the individual, of the parent is, particularly when you feel that the hackles are rising and that you're kind of trying to tell them what to do, is really kind of creating a doable situation for them. So for example, I do know that, you know, guns are very important in your thing, but I'm kind of helping you explain what your child is saying and I'm really worried about the situation. So is it a possible way that you could kind of store these guns, maybe with a family member, like your sister who lives sort of wherever? And, or if you want to keep it at home, how about that we have a way of putting, you know, getting a lockbox, you know, putting the safety locks in there, because I want you to understand why I'm worried about this, right? So it's a very empathetic way of kind of saying, I want your child to be safe. You want them to be safe too, right? So that's the kind of conversation that is really important. Let's talk about how to lower the risk of your boyfriend hurting or killing you. So it's not that you're telling them, leave the person, but you're saying, what can we do to kind of stop yourself from getting into this terrible mess where you may end up dying, right? So let's have a conversation about it. So, you know, each of our personalities kind of drive the way we have our conversations, but this is a particular kind of clinical area where sometimes you just kind of, the risk to me is so high that you have to do everything to keep the person engaged and have the conversation. Because you can prevent something bad from happening and really develop a narrative way of kind of getting at it where you're not kind of losing your audience and not losing other people. So I'm not saying you have to give up or dispose off your gun, but we're talking about safety, right? So questions that we ask in the kiddie arena are your five L's, which is finding out if the gun is locked, whether it is loaded, whether are there little children around. Is this person kind of knowledgeable about how to use the gun? And have the people around anyone in your house feeling kind of low, meaning depressed? So these are a cute way of kind of sort of getting all the L's in, but you're asking them all the right questions, which kind of get at your platform for why you want those guns to be out. Because we know that access to lethal things are perhaps your biggest risk factor. And there is no space between that person and the event when things go wrong. Learning how to kind of do safety counseling. We know now with pediatricians and all that we are training them how to kind of learn about suicidality in a kid by using the ASQ as a screener, and then knowing how to safety plan. So similarly with this, knowing how to safety plan, knowing what your steps are, A, B, C, D, when you're faced with it, rather than leaving it as this vague kind of morass of stuff which is floating around. And once you're faced with it, you don't know what to do with it, right? And most often, when we don't know what to do with it, we don't ask about it. So this sort of is a way of making it your business and knowing what are the steps, how you access it. And once you come to know of it, what do you do to kind of prevent it? And that's where you begin to start talking about safe storage. You begin to start talking about a way of getting that gun away from the person till things are better, and then you can bring it back. But if you don't ask that question, you're never going to know. And then you rue the day because you didn't ask about it. OK, so counseling on access to lethal means. The National Suicide Prevention Resource Center offers a two-hour course on counseling on access to lethal means. So this is a resource that you can give folks, that they can actually learn how to do that. So policy interventions. So these are some of the individual things that you can do within your clinical interactions. Let's look at the policy interventions because that really is something that interests me because this is more of the over 30,000-foot overview, which is going to have an impact. These are some of the strategies that Virginia has kind of tried to work on. And because we've had senators like Tim Kaine, and now we have Glenn Youngkin, who's a Republican but is very interested in mental health as one of the things. So we have an in. You try and get things as much as possible into it. So if you have a Democratic governor, you get a lot of stuff done. And we have had quite a bit of movement, whereas I couldn't have said that 15 years ago. Virginia was a very bad place to practice mental health. So let's start with the ERPO protection. How many people of you have heard of the ERPO laws? Good, at least some. So good, at least I can kind of talk about it. This is a terrific law, which actually was developed at Johns Hopkins at the EPSGV. And they came up with this notion of allowing law enforcement officials, often at the request of the family members, when they're worried or scared about it, to actually petition a judge to temporarily, so that's really very important, temporary removal of firearms from a person behaving dangerously before the tragedy occurs. So a family member can do it at different jurisdictions. Those different states have a family member can ask, or it can be a family member and a law enforcement person, once you come to know that this has happened. They go in and they take the weapon away. And basically, it's a temporary thing. And it can go anywhere from 7 to 21 days. At the seventh day, the penultimate day, or the 21st day, if the threat continues to be a problem, this can be taken away from the person for a period of one year. And so you have to emphasize the fact that this is not a permanent removal of the thing. We're just kind of putting time between this event, because we're worried about it. And we're removing the gun for your own sort of safety that are there. Because this research has been picked up. I know last year, it was 19 states. Now it's 23 states. I was just speaking with Josh Horowitz, who kind of came up with the law. And 23 states have taken it up. Now, the problem with the ERP laws is that you can have the law, but if law enforcement does not implement it, you're in trouble. So that's where your job as a practitioner is in educating people and saying, we need to have you involved in this. Because the data shows that when you remove the gun, you are kind of stopping a tragedy from happening. And I'll show the data on that. So this was the key findings in Connecticut. Connecticut was one of the first key adopters of the ERP laws. And this was like, I'll just go over this. Typical subject was a 47-year-old married male with suicidal ideations. Firearms in 99% of instance when an order was issued removing an average of seven guns per subject. So this was sort of the statistics on what the average person sort of looked like who was sort of a threat. People in Connecticut subject to orders had an annual suicide rate of 40 times higher than the general population, showing the increased risk among this population. So for every 10 to 20 gun removal orders issued, at least one life was saved. So they were able to actually show that with studies which were done in Connecticut. And that is a big shot in the arm for the ERP laws. And the same thing in Indiana was that for every 10 guns removed, one life was saved. So this is a tremendous sort of improvement with the ERP laws and really makes families more peaceful. Because you are sitting on tenterhooks. You don't know what to do. Recently, my youngest one is a child and adolescent psychiatrist just first year in his practice. And he came back to Virginia from New York. And he calls me and says, mom, I don't know what to do. I have this kid. And he has access to guns. And I am really petrified because this is virtual. I don't know how to convince the parents and so on and so forth. And I said, there are ERP laws in Virginia. Why don't you call the police? And he did. He calls me after two hours. And he says, the guy tells me, the police officer tells me he has never heard of anything like this. So I said to Josh Horvitz, you can have laws. But it's very important to do the education piece of it and to get people to really buy into it by sharing the data there. So laws are a good first step. But the implementation of it and making it stick is our kind of job. So you want to make sure that oftentimes we're telling people, you know, GDO or this and that. But we never follow up. So that is a good tool in our hands. And we need to educate folks. But there is data to show that the ERP laws work, actually, by stopping this. Then there are the hospital-based violence prevention programs. We have one in VCU. And it's called Bridging the Gap. And essentially, what it does is it kind of trains, it reduces the recidivism to the repeat victimization that you see with many of these kids. Remember, I talked about the retaliatory kind of engagement in the same thing again and again, where the victim gets counseling services. But not only that, they get connected to community-based interventions. And these community-based interventions talk about job retraining, getting them into having mentors, and all of those kind of things which wrap them around in services, which the person doesn't go back into the same thing. Because we see that a great deal. So this hospital-based violence prevention programs, if anyone's interested in it, that is certainly something that has been shown to reduce repeat victimization and exposure to gun violence. So these are the two, the ERPOs and the hospital-based violence prevention. Then there are community-based violence intervention programs. And these are to do with the things, like I was kind of talking about the INSPIRE program in the East End of Richmond, where you really begin to talk about safe, nurturing neighborhoods and make that a priority, which the city council buys into and the community leaders buy into. Because that's where the genesis of the aggression is occurring, where these kids have a sense of a foreshortened future. They don't think they're going to live beyond the age of 21. They have gone through so much of trauma that they end up identifying with the aggressor. They kind of begin to start the smoking of the weed at age 12. They begin to start getting into a deviant, delinquent peer group, and eventually end up getting into the gun culture, because the guns really are a way of many things, self-protection, safety for themselves, the way they look, the foreshortened future piece of it, and also the fact that it's very lucrative. But before you can say Jack Robinson, the whole thing sort of explodes, and you have a dead person on your hands. So that can only happen when you begin to do some re-engineering from the perspective of keeping those historical racism, which goes into the redlining and where these kids went to school, where they go to school, what they're allowed to do, what they're not allowed to do, what access they have to what you and I just take for granted. All of those things are the genesis of all of that. So if we don't begin to tackle those, we'll be tackling things on the top. And as a prevention person, I am a tertiary care person. I see clinical. I see kids coming out of my ears. But my heart sits in the area of prevention, because what I see in the downstream is really a product of what went on there. So although this is not connected to gun violence, but I always make it a point to tell people, women at high risk for substance abuse, particularly alcohol and nicotine, third trimester of pregnancy, what you do to the brain of the fetus, is what I see in my clinic at age five. So if we can begin to do prevention stuff with that third trimester mother who's at high risk, I would have done a tremendous job for that life of the baby. So we have to start beginning to think in terms of a public health perspective and a prevention perspective, although that's not where we do our major work. But if we begin to be the voice which can kind of talk about the data, which supports this, I feel like it's a major thing. Now I'm going to go into what downstream are the things that different lawmakers and people who kind of are worried about this stuff talk about, which is dangerous weapons ban, which are military assault weapons, flash suppressors, silencers. I mean, there's no place for them. So we need to kind of ban those things from the streets that they should be available only to people who kind of need them for the purposes of doing their job, like defense, for example, or law enforcement. Universal background check laws to prevent domestic abusers, felons, and others prohibited from purchasing or possessing arms. These are common sense laws that you would want everyone to have universal background checks. And it's really America is kind of what we do best, which is that every individual sort of has their own laws. But these are common sense things that we should. Strengthening the child access prevention law so that when you have a situation where a child has ended up getting injured because of irresponsible behavior where these guns have not been stored properly, there should be appropriate accountability to the fact so that when people will begin to pay attention to these things, that I'm going to get into serious trouble if my child experiences this. And we've heard of so many of those cases where the kid will pick up the gun, and the next thing you know is inadvertent shooting because they didn't know it was loaded. And you have parents dying. You have sheriffs dying. You have all kinds of things like that. So we have to have penalties, which really have teeth in them. Reporting lost, stolen, and missing gun laws, because these things go into the underworld, and they create their own havoc. So when a person loses a gun, you should go and have that event registered so that there's some accountability to the whole thing. So it's really kind of trying to corral it from many different arenas. Local regulation of firearms in public. This is this huge concealed carry and permit to carry type of stuff, which is scary to me. I just kind of feel like I go into a restaurant, I have no idea who's sitting, what are they doing, are they inebriated, are they thinking properly. I'm scared now of actually going. And this is because there's such kind of laxness in that approach. And I don't know what people are thinking. But these are, to me, common sense type of things, where you are making sure that you give jurisdiction to places which can say, I do not want, I do not allow this. So for the first time, it's seen in the Richmond airports where it's very publicly posted, you cannot bring your firearms and your carry-on luggage. And I'm saying, go figure. That people have to say that now, because it's become such a problem from my perspective. One handgun per month purchase limitation, and then the whole notion of the disarming domestic violence. This slide is really to talk about the social determinants of health. And any of you can get engaged with many of these things, because they are the genesis of aggression, which is housing assistance, child care subsidies, tax credits, livable wages, cleaning up vacant laws, because this has been shown to be affecting aggression, which is planting grass, trees in high-risk areas. There are studies which show, actually, that this reduces aggression and violence. I know it sounds far-fetched, but it really is being shown by data that that is true. And then looking at specifically the lethal weapons, which are your guns, safe storage, street outreach, buying bad guns, that kind of notion, and hospital-based prevention programs. So this gives you the roadmap of what are the different things that you can be considering. So actually, we just have about how many minutes do we have? Oh, we are in good shape, then. I was rushing through. So basically, each of you can have a voice in the place where you want to get involved. I have not spoken at all about trauma and the whole notion of how that produces people into adulthood and how they go. But as a child psychiatrist, I cannot go without talking about how important that is, that our young children are our destiny and our future. And if we don't begin to start investing in the programs which support children's development, we have missed the boat. So along with what we do, at least one thing that you can think of doing is this talk about safety devices like a lockbox, a safe firearm storage practice in the home. And then as tertiary care providers, be thinking of other things that you could possibly counsel the family and people on. So if you are into advocacy, one of the things that you could do is to begin to talk to your advocacy people or your lobbyists or people that you are kind of engaged in, where there are sustainable programs and policies to address the underlying conditions that contribute. And these, again, they seem like pipe dreams, but you could attach yourself to a small thing that you kind of do. In my own book, what I began to do was I used the child behavior checklist as a way of framing the notion of where the family was in their development and whether they were just kind of requiring well-being type of wraparound services or were they at risk or whether they need tertiary care. And so essentially got them out of the place of what put them at risk into a better place as far as their own mental health was concerned. So I just picked up that. I'm just kind of telling you an example of what I did. And obviously, none of us can kind of approach everything, but you can look at it from the perspective of, hey, in my tertiary care work, this is what I do, but in my primary and secondary prevention, I may want to do this as far as this is concerned. And then just pick that up and kind of connect with your local organizations. And whenever you have an advocacy day or an assembly day, kind of go there and see if there are any bills that are kind of sitting which can promote healthful living. So become involved with that. And so I'm going to sort of end by saying that this is not about taking guns away, but just to keep them, make them safe, understand high-risk populations, and alter policies accordingly. And so our next step is to really develop a bipartisan voice that applies a common-sense approach to the safe use of firearms. And for that, you have to cross the aisle and really bring people into this conversation to say, we want to keep people safe. Would you agree? And how can we do that in a way which does not step on anyone's toes, does not take away anyone's rights, but how do we kind of come up with a common voice? And to me, that's one of the things that we could do as health care providers and hopefully have an impact. So getting involved, use your voice of authority, your physicians. And people do sit up and pay attention. Again, just don't go in and say, the Wild West, I'm sort of going to take this on. But developing a presence in committees, developing a presence in the community, and really doing good work, and then your voice begins to get heard. Because people say that this is not just a person who just pouts off stuff, but they actually do stuff. And I do things like, I'll say, if I can help you in any way, I'd be glad to. So people would call me and say, can you see this kid? And I'd say yes, and I'd see them. So I was really developing sort of a, and I really did want to help them. It wasn't any quid pro quo kind of a thing. But I do like to see myself as sort of a holistic sort of an approach. So what that did was, then when I would sit with them and I had something to say, they would listen. And so you kind of develop this bi-directional collaboration with folks. Contact your legislators. If there is a bill which you feel doesn't take long, just talk to the LA and kind of say, if you'd like, I can kind of give a written testimony. I do that many times. I'll do a little op-ed type of piece there, and I'll kind of send it over. And they'll use it if they want me to. I did a virtual testimony for a SSRI bill at the General Assembly this way. So you can do things like that. Follow the bills. You know, if your state is kind of considering that, get involved. It may seem a gargantuan, it may seem like a hill, but I think if you just spend a little bit of time getting, if you're interested in advocacy, that is. Educate others. Write op-ed. This is not hard. You all have probably ideas. That's why you're sitting here. And you'd like to kind of take a situation up and make a comment on it. And I'm going to do one, by the way, an op-ed on the ERP laws and making a case for law enforcement needs education. So give us the money. Because the Department of Justice took all the money from the feds, and they're doing nothing with it. So I want to access that to start educating. So do that. Speak at professional conferences like I have. I'm sure that, if nothing else, I've probably given you 5% of additional data than what you had known at baseline. And learning opportunities at your place of employment. My whole thing is going to all the universities in Virginia and giving a grand rounds on gun violence and getting people excited about the concept of, hey, you have a voice there and working on this topic. Lead a discussion group at your workplace, a worship professional group, and more. And you learn from that. You learn other viewpoints. And you kind of have to then say to yourself, how do I solve this? Resilience is always the concept is you come up with a barrier, you kind of go around it, you figure out a way. Because these are all man-made laws. Have that confidence in yourself. Social media advocacy. Telling your story to raise awareness for gun violence effort, promoting research, reports, et cetera. So there are a lot of ways that you can kind of cut this by. Join an advocacy group of your professional group. So MSV, we have Medical Society of Virginia. These are my Virginia slides. So Medical Society of Virginia, you probably have a medical society there. APA, AMA, et cetera, et cetera, et cetera. All of the acronyms. But who is involved in this work? And how can you kind of say, hey, I'd like to do something with this? So that's how you could kind of. These are some of the statements by the American Academy of Pediatrics. And I think they're very brave. My feeling is, in comparison to ACAP and stuff, APA, just kind of, sorry, the AAP, is very, very quick in making position statements and what makes perfect common sense. So I really love them for that. That they kind of don't worry about what is politically correct. And they are a very strong advocacy group. The Medical Society of Virginia is another one that does a lot of these regulation stuff. So just know what is around you and what you'd like to do. American Psychological Association has also kind of talked about violence prevention. And then there are so many materials which are available for all of these. So with this, I'll end. And I'll kind of leave some time for questions. We have about 20 minutes or so. So I've done good. OK, great. Any questions? So, I have a question, I'm also the moderator, but when you started this work, you know, and Virginia, you mentioned that the landscape wasn't as friendly towards gun violence and there's even laws preventing kind of working and researching gun violence. What were some ways that you were able to kind of continue to push forward or partner with, who were you able to partner with in those initial days of talking about gun violence and needs for your patients? Very good question. I think that I've always, as a person, I've always sort of followed my passion. Even at this ripe old age of 67, I still carry the same enthusiasm and the same sense of outrage with some of these things, so never lose your outrage at what seems to be a travesty. So I've always kept that open and kind of, so finding out people within your state who have similar kinds of views on things and aligning them with them, I've always felt that you don't want to lose your core central work that you do because that informs everything that you do. So my work with the juvenile justice system informs how I've learned about the lives of people and understood without the judgmental piece. So it's all been sort of a process of little pieces which have kind of come together. I raised the issue of the gun violence stuff at the ACAP assembly, and at that time became very aware that it's a very polarizing issue, and even the membership within ACAP had strong feelings about it. I tried to understand that rather than push against it and it really becoming my own echo chamber, really trying to understand where people were coming from. Because if you don't listen to the other side, you're not going to get very far because you are going to get barriers sort of put up. So you learn from that as well. My work with the Virginia Tech panel helped a lot because I had a lot of connections now with government agencies, although they're not very helpful, but you kind of sort of begin to sort of talk about what you are best at, which is the damage, the emotional damage and the... So that really is our lane, right? And then begin to look at the deeper kind of things, because societal re-engineering is not in our hands, but we can inform it. So when I would go and sit with the communities, I really kind of plunged headlong into that area, and I felt I had come to my own when one of the discussions, and these were predominantly 98% African-American folks that I was kind of working with, and one of them turned to me and said, what would you know? You're an Asian woman, you don't know anything. And I said, thank you, I now feel included because you acknowledge the fact that I'm different. So having a stomach for that kind of a thing, and really being very comfortable with the idea that it's going to be two steps forward and three steps backwards, because it's very difficult work. So then I got in connection with Johns Hopkins with their violence prevention program and asked them, what can we be doing? And that's where I got the idea of the educational piece, which is the grand rounds on this stuff and getting used to it, then testifying for any bills that would come up to talk about these things. So there are multiple kind of different ways, but as a clinician, what you bring to the table is the plethora of clinical information that you are bringing up that no one can tell you you don't know. You know, because you see it. You see how these kids develop and where they're coming from. To me, the work in my juvenile justice work informs every bit of my work, because when I get the thorough developmental history, trauma is rife. It's huge. It plays such a huge part in what goes on. So I feel very confident about where I'm coming from, and I realize the complexity of the thing, and I'm humble about it. But I also know that if we don't speak, there is... So we all have to have a collective voice in this public health approach to this work. Any questions anyone else has? Anyone who has done some... Go ahead. Well, I worked in our area to help get the suicide deterrent system on the Golden Gate Bridge. And there were five failures before we started in 2004 or 2005 with Mel Blaustein, who then was president of the APA Foundation local and was interested in this and got people involved, including family members, survivors, and all of the things you've talked about, like being active with the legislatures and seeing what people can hear. I think your approach is a very good one, and all those people you talk about safety with who know, because they live in a violent neighborhood and their kids are upset, I hope that convinces them to no longer vote for those legislators who automatically reject anything about appropriate gun safety laws. I mean, all the data suggests that the population is already there, but our legislators are miles away in many states. Not so much in California, but... Yeah, other places. So I agree with you, and I... But the rest of the country, it's just ridiculous. And I think the reason why the legislators don't listen is that as soon as you bring this topic up, they talk about the Second Amendment and removal of guns. And you have... Yes, it's a reflex. So you have to... I've learned that the only way you can get beyond it is not to threaten that very thing, and to just kind of go with safety as sort of your topic area. Then I think you can have... And probably having the conversation more quietly and... When I had the Virginia Tech shooting, I was just appalled where the first panel discussion, they didn't come. So the panel hearings, and these were open to the public, so you had the whole room full of people coming, including the victims' parents, families there. And by the second one, the NRA was in full swing. They were here. And it was awful. And I was just like struck, and at that time I was one of these hot-headed kind of folks who couldn't moderate my voice. And I and the judge on the panel, the legal person, we were the two who were most vociferous and vocal about the fact that this was appalling. And then I realized about two years after that, that that was perhaps not the best approach to it. It was really, you have to become... You have to cross the aisle and really begin to think in terms of what's threatening folks. I mean, I came to your talk today because I can't watch the news for the last two years. I mean, literally, there are three incidents of... Yes. It's awful. It's awful. And it gave me a little taste of what it must be like to be an African-American family in Chicago. Because I'm also from Chicago. I've heard of so many families that have lost children. It's scary because... I think people want to hear about it. Yes. But the moms will tell, actually... For the first time, I've begun to hear the genuine fear in moms when they talk to their children and they say, this is not... I'm not trying to scare you or whatever. This is reality. If you don't do X, Y, Z, you're not going to come back. So they're very scared, and I can see why. I'm scared. As I said, you never know what's coming around the block here. So we have to develop that sense of the civility and really... The world's never going to be a totally safe place. And I think that's what we're trying to do, and I think that's what we're trying to do I was really petrified. I said, it's going to go backwards. He has made mental health his thing. So I was actually at the first lady's roundtable on looking at how do you implement behavioral health changes in the structure of the government. I was shocked. So there's perhaps some... The gun control piece of it is I really think that the answer is how to become bipartisan. Otherwise, people just kind of, they're not listening at all, including the membership wake-up. It's possible because you know we shouldn't give up. It's just too crazy. I mean, it's so different from places like Australia that stood up and looked at it. Oh, yeah. I think that in some ways, we get to be the laughingstock of the world, right? Right. I'm afraid so. Yes. But that's not the answer. Thank you for being here.

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