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(gentle music) - [Announcer] And now, the Cascade PBS Ideas Festival, featuring journalists, newsmakers, and innovators from around the country in conversation about the issues making headlines.

Thank you for joining us for Revisionist History, Unlocked and Unloaded, with David Hogg and Dr. Babak Sarani, moderated by Malcolm Gladwell.

Before we begin, a special thank you to our session sponsor, the Washington State Hospitals Association.

We'd also like to thank our stage sponsor, BECU, and our founding sponsor, The Kerry & Linda Killinger Foundation.

Finally, thank you to our host sponsor, Amazon.

- Hello, everyone.

Welcome to the Cascade PBS Ideas Festival.

My name is Malcolm Gladwell.

I am the host of the Revisionist History podcast from Pushkin Industries, and I am joined today by two wonderful guests, David Hogg, who is the co-founder of the March for Our Lives movement and gun control activist, and Dr. Babak Sarani, who is the head of trauma surgery at the George Washington University School of Medicine.

(audience applauding) Thank you.

So we're here because in my last season of Revisionist History, I did a series on gun violence in the United States, which asked all kinds of, told all kinds of strange and hopefully interesting stories.

But there was one question that we brought up in that series that I wanted to return to today, which was that I became convinced that there was a disconnect between what's happening on the ground with respect to gun violence in this country and the way we address it from a kind of policy perspective.

So what I've done today is I have got someone who's concerned with the big picture policy perspective and someone who treats gun violence on the ground.

And I thought what I would do is hold a conversation with the two of them and see if we can, see if it's true that there is a disconnect and whether we can try and resolve it.

You are a trauma surgeon in Washington, DC.

- Yes.

- That I'm assuming is a very different proposition than being a trauma surgeon in Westchester County in New York City, in New York State.

- Probably.

I think so.

- Yes.

- How is it different?

- Well, I'm not familiar with Westchester, New York State, but I'm gonna say that D.C. is an urban environment.

And so in the urban setting, one deals with more trauma.

There's more cars, there's more people, there's more activity, there are nightclubs and all the things that get people into trouble and injured.

And in regards to gun violence, when we talk about gun violence, we're really by and large talking about an urban phenomenon.

There are absolutely firearm related injuries in rural and suburban America.

That is a true statement.

But they are a very different demographic.

- Look back on your last months and describe to me the busiest night you had over the last month.

- Well, so at George Washington, we are considered a medium volume trauma center.

We're not considered a super high, crazy busy, as you might see, for example, in LA County.

So to put that in perspective, we have about 1,500 or so admissions.

We have about 1,800 patients that we see.

And in a medium volume trauma center, one out of four has been shot.

We have a 25% penetrating trauma volume.

That number went up to about 33% during COVID.

- What's your worst night of the week?

- These days, it's unfortunately a little bit of a roll of the dice.

In general, Thursday, Friday, sometimes Saturday are gonna be the more busy nights, Monday, Tuesday, less busy.

But I certainly would never go to work on a Tuesday and expect to get some sleep.

- Yeah.

- Yeah, it wouldn't happen.

- And describe to me the patterns of gunshot victims that you're seeing.

- So in urban America, whether you're in Washington or as I mentioned, LA, Chicago, Miami, wherever you may be, in one of the major cities in the country, the demographic you will see who has been shot by and large will be a young African-American male.

It'll be someone who's African-American male and probably between the ages of 15, 16 to maybe about 25 to 30.

We have seen that in the last five year, 10 years push up.

All of a sudden, I am seeing shootings in patients who are now in their 40s and maybe early 50s.

That was very unusual back in the day.

Those types of firearm-related injuries back in the day would have been more likely than not suicide.

Nowadays, we're seeing those as part of the homicide.

So there's been that demographic shift, but still the majority are young African-American male.

And then over the last 20 or so years, the big difference has been multiple shootings, multiple hits.

So, and I'm sure David will talk about this, but it's unheard of for someone in the United States to have anything other than a semi-automatic handgun.

- So in the patient population that you're seeing that had been shot, what percentage of those would have been shot more than once?

- Oh, almost everybody.

It'd be all very unusual to have someone who's been shot only once.

And if that is the case, much, much more likely than not, that person was not the intended target.

- Yeah.

So a typical victim would have how many shots?

Two, three?

- I would say on average, everyone's been shot about two times.

So they have about three to four holes in them.

- Do you keep track of the guns used in the victims that you see?

- We don't.

The police department does.

And the majority, I think, I don't know this to be a fact, but in general, we're talking about nine millimeter handguns.

Increasingly though, I will say, and I'm positive David's gonna talk about this, over the last five to seven years, we have, even in DC, we've seen a distinct rise in the number of shootings related to what are referred to as long guns.

You guys would call them assault weapons.

- Describe a particularly difficult case that you've had recently.

- This was a gentleman who was in Washington, D.C.

He's a retired metropolitan police officer.

He now works as a school police officer.

And he was going to work at this elementary school when someone who was mentally deranged had an assault weapon and I think by report, over a thousand rounds of ammunition.

And I guess fortunately, the shooter started to shoot before the end of school bell had rung.

So most of the kids were still inside.

He hit the police officer who was my patient.

He also hit one of the kids who had a broken arm, but thankfully survived.

He hit another woman who I believe also survived.

The police officer who came to us because it was an assault weapon wounding, I mean, his liver was simply missing.

He ended up removing over half his liver in addition to multiple different organs, kidney.

So he now only has one kidney.

He got close to 100 units of blood over the first few hours.

By all criteria, he should be dead.

We have a, most trauma centers have a device that's like a balloon you can put inside the patient's body and it stops blood flow.

You can only use that balloon for about 30 minutes.

He had it in his body for 20 hours.

I remember going to bed at around four or five in the morning and I just passed out and I just told my residents, here's the plan.

And if anything deviates, call me.

And I think I probably got maybe two, two and a half hours of sleep, got up around six 30 in the morning, went back to his bedside again.

- Yeah.

Now, what's your emotional response to doing your job?

- It goes from elation to extreme remorse and sorrow.

You know, one of the things I learned in medical school, someone said this to me and it's been in my head ever since.

There's only two things a doctor can do that nobody else can do.

One is to declare life when you're born and we say the time of the birth.

And one is to declare death.

And, you know, death sucks.

Period.

- Yeah.

- That hurts.

- How many patients come into GW that you cannot save?

How often does that happen?

- Thankfully, the majority we save.

I think our mortality rate across the board for all, that means, you know, car crash and falling down the stairs, gunshot wound, everything.

It's probably, I would guess 2%, one and a half, 2%.

It's pretty low.

- I read a study that was done that said if the level of trauma care had remained constant from the 1970s on, the homicide rate in this country would be something like three or four times higher than it is now.

Do you think that's true?

- I'm sure there's an element of truth in that.

And I appreciate on behalf of my colleagues and my forefathers in medicine, your comments.

That's a huge compliment.

But I think there's also room to continue to improve.

I would certainly never say we're good enough.

I would say the same thing.

The easiest way to prevent death from injury is to prevent the injury.

I know that sounds trite and stupid, but it's true.

So just take examples that we've learned over the last 50 years.

Seatbelts, the way the roads are designed.

When you go around a turn, the asphalt is banked for a reason.

The way your tires are designed to prevent the car from slipping off the road.

Drunk driving laws, helmet laws for motorcyclists, on and on and on.

We've learned time and again that the best way to prevent death is to prevent injury.

So I think you're right, Mr. Gladwell.

Things have improved and that hopefully has impacted favorably.

I think there's always room to improve more as medicine continues to advance, but nothing will ever beat prevention.

And that's actually, that's born out in studies done back in the 1980s when we realized when someone is injured, they follow that probably a death has this trimodal distribution.

By far the highest peak, by far, is at the moment of injury itself.

So the second peak is bleeding to death.

That's where I come in.

The third peak is in the intensive care unit because you just don't recover.

So the best way to prevent death, the highest peak in the graph is to prevent the injury in the first place.

- Yeah.

So how does your experience as a ER doctor inform the way you think about the best policy approaches to ending gun violence?

So if I made you, we have a new president and he says, he comes, knocks on your door and says, "I want you to be gun violence czar."

- Yeah.

- You get to do whatever you want.

He gives you a magic wand.

They have one apparently, they just don't use it.

What do you do with your magic wand?

- I think there's a couple of things.

At least from my personal perspective in the United States, we're not going to ban guns.

That's my personal belief.

There's 400 million guns, there's 300 million people.

We don't even know where the guns are and nevermind the constitution.

It's just not a logistically feasible lift.

So there's that.

But I would posture that no one should have 1000 rounds of ammunition and no one knows that person just bought that.

You're not defending your kids with that.

I surely am going out hunting with that.

There's a reason why you have 1000 rounds of ammunition and we shouldn't put limits on things.

That's what I would say.

- Yeah.

(audience applauding) - David, you've been listening to Dr. Sarani.

I'm curious, before I ask you a specific question, do you have any responses to any of the things he said?

- I think the two things that I think about most in response to what I've heard are one, the people who don't make it to the ER.

Truth be told, you know, most victims of gun violence or gun deaths in the United States, two thirds of gun deaths typically don't make it to the ER.

It's 'cause they're self-inflicted gunshot wounds that typically happen in more rural and suburban communities, often with less easy access to healthcare.

And typically it's older white men with easy access to firearms that die of deaths and desperation.

And I just wanna touch on this for a minute 'cause I think so many people say this is just a mental health problem when they don't wanna address the fact, you know, the shooter in Parkland, for example, obviously he had mental health problems, he had multiple therapists, but he also was an anti-Semite.

He also was a racist and talked repeatedly online about how much he hated black and brown people, how much he hated immigrants, so on and so forth.

Hatred is not a mental illness.

We should not be using mental illness as a scapegoat.

(crowd applauds) We need to address why they pulled the trigger too.

We do need to address mental health and those two thirds of gun deaths that are suicides that typically don't make it, unfortunately.

But the other thing that I think about too is just how, you know, clearly there's a lot of pain that you have to endure in your job.

Telling parents that their kid is not, they're never gonna see their kid again.

You know, increasingly our politicians are putting our doctors on the front lines of this issue.

And of course there's a role for doctors to play here.

But by the time that you are treating a gunshot wound, that is already a policy failure because somebody is likely going to die.

And we need our politicians to stand up and have the courage to actually do something about this issue and not just be afraid of the NRA and the gun lobby, but actually stand up for our kids.

(audience applauding) - David, what's the, so be more specific.

So in response to what Dr. Sarani said, if you, if I'm not gonna give you the magic wand, but I wanna talk to you to talk about- - I'll take it.

- Only he gets the magic wand.

But I wanna talk.

So what is the, if you could only do one... if you were to make one intervention, one pass one bill in Congress, what would it be?

What's at the top of your priority list as a way of addressing gun violence?

- If I could do one thing, it would be to federalize Massachusetts state gun laws.

And you might be asking, well, what are those laws?

You know, Massachusetts has a gun death rate 70% lower than the rest of the country.

And obviously every state is not Massachusetts by any means.

But even if we could cut gun deaths by 30 or 40%, that's still a victory.

That's 30 or 40% less people coming in to the ER, right?

And in Massachusetts, you can still get a gun.

They essentially have an interview process.

It's kind of like, if you wanna get a car, it's a similar process for getting a gun.

You basically, you need to register the firearm.

You need to have an interview with a law enforcement officer.

You need to prove that you're proficient and safe with the firearm.

And there are certain limits.

For example, there's limits on how many rounds you can have in a magazine.

Is it easy to get a gun in Massachusetts as it is in Texas?

No, but guess what?

I can't remember the last time I heard about a school shooting in Massachusetts, right?

It's a gun.

It shouldn't be easy to get because with rights come responsibilities and no right is absolute in this country.

- Yeah.

Dr. Serrano, you did a study of mass shootings.

And I want you to talk a little bit about why you did that study and what you found and how that ought to inform the way we think about gun violence.

- We did a series of studies.

My two great partners in this endeavor, one is Dr. Reed Smith, who's an emergency medicine physician and Mr. Joff Shapiro, who is a critical care paramedic.

It was actually their idea to do the study.

So they get all the credit, honestly.

I was just the guy who typed on the word processor, so to speak.

What we did is we set out with the help of an attorney.

We got our hands on several hundred autopsy reports of multiple mass shootings around the country.

And was there an opportunity to save their life?

And what we found is 85%, roughly speaking, 85% of them had no opportunity to save their life at all.

They were fatally injured at the time of the event.

The only way to prevent that death would have been to prevent the event.

And we're talking now about the mass shootings.

We're talking about the Parklands, Pulse Night Club, Route 91, which was the Mandalay Bay, Las Vegas shooting, San Bernardino, Columbine, on and on.

And the other 15%, we did not say that they were preventable per se, 'cause it's hard to say.

Who am I to say what is preventable, what isn't preventable post facto?

We just said they were potentially preventable had they gotten to the hospital in time, there is a chance that perhaps they could have been saved.

It's a lot of adjectives there based on the nature of the wounding.

And the problem is getting the fire department and the paramedics to infiltrate that scene as quickly as possible whether it's an active shooter.

The point being, we have to get to the victim as fast as possible.

We need to extricate the victim as fast as possible.

And we have to get that person to a hospital, to a trauma center specifically as fast as possible.

And maybe we can take that 15% number and whittle it down to something less.

That's what we were able to demonstrate.

- You also, you had an additional finding though about the nature of the guns used in the shooting.

- We did, we did another study and this was a happenstance as we were reading through all these hundreds of autopsies for a lot of them, the medical examiner would comment on the type of firearm used.

Sometimes they would say this person was shot with a handgun.

Sometimes they would say this person was shot with an assault weapon.

And we realized, oh my goodness, we've got all of a sudden this data trove and we started to look and ask the question, well, what are the chances you're gonna die if you got shot with a handgun versus an assault weapon which I thought would be a no brainer, like no kidding, the assault weapon is gonna kill you.

So our findings were, if you, from our data set, if you were shot with a handgun, if the shooter had a handgun, you were far more likely to be shot more than once and thus far more likely to die, far less likely to have an opportunity for rescue as compared to an assault weapon.

People have taken that study and said, aha, assault weapons aren't that bad.

That is not what the study says.

That is not what the study says.

And we're actually now trying to go back and redo that study factoring in the shooter's distance but it's very difficult to get that information because the government doesn't track it.

I actually called the Bureau of Alcohol, Tobacco and Firearms and I said, do you guys have information on the distance of the shooter to the victim?

Do you track that?

And they said, no, we don't track that at all.

So the government unfortunately specifically is not funded and in many ways precluded by law from studying gunshot wounds.

So we're literally going through CNN reports and local media reports, which, you know, aren't all that reliable.

When you talk about something as minuscule as distance, they're gonna say the shooter was in the parking lot.

Well, what does that mean?

As we're trying to figure it out, but bottom line to your question is they're equally lethal in my opinion, a handgun and an assault weapon, it just depends on distance.

And if I'm standing in front of you right now and I have an assault weapon, I'm far more lethal than I would be with a handgun because of the nature of the assault weapon.

- Yeah, yeah.

But that, you know, there's so many interesting things, part of that, interesting implications of what you've been talking about.

Number one is just that small, small point, but the thing you mentioned at the end about the difficulty you have in getting information about these cases.

I'm assuming it's a lot easier to get information about someone's appendectomy than it is about them being shot by in some kind of public event.

I mean, that's sort of crazy, right?

- It is, it took us, we did another study where we looked at survivors of the mass shootings.

The dead patients weren't as difficult to study because a person who's died is no longer considered under the regulatory guidance of research.

You don't need their permission.

If the state allows you to look at the autopsy, you can look at the autopsy.

If they don't, they don't.

But if you're alive, then you fall under privacy laws.

It took us three years to look at the survivor study that we did because there's not that many survivors.

David's right.

To your point, it is far easier to get information on appendectomy than this.

Nobody wants to look at this.

- Right now, the conversation we're having is out of proportion to the size of the problem.

So you, one of the things you mentioned, David, was you started talking about the problem of suicide.

The problem of suicide is actually larger than the problem of homicide, if I'm right, in this country.

But it's talked about this much, right?

As opposed to, you were just talking about a constraint on the ability of people in your position to talk in an academic and scientific sense about gun violence.

If we were to remove those kinds of narrative constraints, and if we talked about gun violence in a manner appropriate to the size of the problem, would it make it harder for the other side to run so much obstruction?

- Totally, I mean, for a long time on the research note, it's important to note that for most of my life, it was literally illegal for the US government to study the effectiveness of state gun laws because of something called the Dickey Amendment.

That literally, until basically from the year that I was born in 2000, until I was 18 years old when we finally repealed the, we changed the wording in this.

Not only was it illegal to study the effectiveness of state gun laws, which had an overall chilling effect on studying the issue in general, it also got about pretty much zero funding, right?

We're raising an entire generation of young people who wanna do things about this right now, who want to get active, who wanna go study public health, who wanna become surgeons, who wanna do stuff about gun violence and become public health practitioners, but we are not giving anywhere near the proportional amount of funding as we do to other issues to the issue of addressing gun violence for research funding at all, and it's not sexy.

We need to have way more research on the issue, and we need to make sure that those kids who right now are going through shooter drills and want to become those public health practitioners, that they can actually get a job studying the public health of this in the first place.

And the great thing about that, we don't need to deal with the filibuster.

We can do it through reconciliation and we don't need 60 votes, right?

So that's a low-hanging fruit that we could do right now.

We also need to have, (audience applauding) we also need to have, I wanna establish NHTSA for addressing gun deaths in the United States, not just gun homicides, but also unintentional shootings, domestic violence with firearms, and also gun suicides, because gun suicides are preventable.

They are.

So we need to fund that, and we need to look at what we did with big tobacco, right?

You can still smoke in the United States if you want, but we put reasonable constraints on it to make sure that they can't advertise to minors, to make sure that people know the dangers associated with the use of that product.

And you can still go and get it, but people know what the real dangers are.

- When you look at policy-focused attempts to bring about gun control, in many ways, we're going backwards, right?

Or at least the court is pushing us backwards.

So maybe it's time for, like I said, for a kind of rethink, where we just say, let's change the conversation.

- If I can frame that for a second, the most common cause of death from age one to age 19 is gun violence.

Many people will use the word accidental, and he didn't.

He used the word unintentional.

We have to change our mentality.

A one or two or five or 10-year-old who gets shot, that is not an accident.

That's because the firearm owner kept that gun loaded and unsecured and readily accessible to the child.

So it is all about changing the way we think about guns.

And it's not just the government needs to legislate it.

We also need to change our behavior.

We need to change our thinking.

And we have to stop using the word accident.

It is not an accident.

It happened because you were not responsible with a firearm that you had.

- Exactly.

- Yeah.

(audience applauding) Where is your level of optimism right now, relative to when you started, 2018?

That was Parkland, right?

- Yeah.

- Give me your level of optimism on a scale of one to 10 then and now.

- I feel like there's a fine line between optimism and delusion.

And too often they feel like the same thing.

Look, ultimately people are like, how do you stay hopeful?

For me, it's not a matter of hope, Malcolm.

If we listened to those people who said that we were just a bunch of dumb kids and we couldn't change anything, my mother may not be alive right now.

Because after Parkland, we went and we actually did have the audacity to believe that we were going to change what was possible, not because we were hopeful, but because we had righteous indignation at what had happened at our school.

And after Parkland, we passed a red flag law that can disarm people that are at risk to themselves or others.

There was an NRA supporter that sent a death threat to my own mother that said, "F with the NRA "and you will be DOA."

We used the law that we passed after Parkland to disarm the man that threatened to kill my mother.

- Good for you.

- Yeah.

- And guess what?

Guess what?

That law has been used over 12,000 times since Parkland in Florida alone.

That is part of the challenge that we have to deal with here.

You're not gonna hear about the person who doesn't come into the ER because of the background check that stops that person from getting a gun.

You're not gonna hear about the shooting that doesn't happen because of the laws that have changed.

And I think it's not a matter of how optimistic I am.

I think what I look at is the general course of history.

And when young people stand up in the way that we have around gun violence, and we say, "We're mad as hell and we're not gonna take this anymore," to reference a very old movie that some of you may know.

(audience laughing) - I'm old enough to remember that movie.

- But when they stand up and do that, things do change because ultimately young people have the greatest thing that you can have on your side in politics.

And it's something that not the Koch brothers, the NRA, or anybody else can buy more of, which is time.

And the fact that no matter what the Supreme Court says, we're gonna outlive them.

- Yeah.

- Right?

- David, so.

(crowd applauds) But, and look at this, as one final point.

As one final point, I don't want you all to think that everything's gonna be solved overnight, but I want you to know the power is within each and every one of you, and it has to be, 'cause no single person is going to solve this.

No single person is going to save us other than yourself.

We have to save us.

Nobody is gonna come here, but we are making progress.

And the reason why I know that is because the first Gen Z member of Congress, guess what he did before he was in Congress?

He was March for Our Lives National Organizing Director.

Less than a year after he was elected, I got to see the President of the United States be introduced by Congressman Maxwell Frost for the creation of the Office of Gun Violence Prevention.

Right?

We are not, we're not just staying on, what gives me hope is that we're not just staying on the outside, we've realized if our government does not change our gun laws, we're going to change who is in government.

- Yeah.

Thank you, David.

We are, sadly, I've been told we're out of time, the music's gonna start, we're gonna be dragged from the stage, but-- - I don't wanna follow that.

(laughing) - Dr. Sarani, thank you so much.

David, thank you.

- Thank you.

- All right.

(audience applauding) Bye-bye.

(gentle music)