Getting science into policy for gun control and NHS reform
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Welcome to Medicine and Science from the BMJ. I'm Duncan Jarvis, multimedia editor. In this episode of the podcast, we'll be hearing about how science can be transformed into policy. Later, we'll hear about citizen assemblies, a form of democratic participation that has helped clarify some key healthcare issues, from assisted dying to abortion access.

We actually don't really have too much of a shortage of evidence to inform the policy options. And we do, to a large extent, kind of know what's going wrong, but also know that fixing the problems is going to require bold action and some really difficult decisions. But first, we turn to one of the seemingly most intractable issues when it comes to people's safety in the US. That's gun control.

One reason it's been so hard to change policy there is that discussions were happening in an evidence vacuum as federal research funding into gun control was restricted. But new evidence is emerging and that discussion is beginning to change. And to talk about that, I'm joined by Luis Claravis, an academic who studies gun control, and Shannon Watts, who leads one of the most successful pressure groups demanding change.

I'm Shannon Watts. I'm the founder of Moms Demand Action. It is a grassroots gun safety organization led by volunteers, mostly women. And I started it after the horrific mass shooting tragedy at Sandy Hook School in 2012. It's become the largest women-led grassroots movement in the nation and has had significant successes in changing gun violence in this country legislatively, electorally, and culturally.

Yeah, my name is Luis Clarivas. I'm a research professor at Teachers College at Columbia University in New York City and wrote a book called Rampage Nation, which was kind of one of the first books that entered into the mainstream about mass shootings and have been focused on this topic since.

Lewis, you've written an editorial from us and the general sense I got from that is that we now have evidence that the greater the restrictions on who has access to guns, but also on how guns are being used, the training around that, and also what kind of guns are on the market. All of these are contributing to fewer gun deaths.

So tell us, how has that evidence started to emerge? Yeah, that's right. So in the last 10 years or so, and I'm kind of painting with broad strokes here, but there have been two different approaches to this. One is for one group of states is to be more permissive in terms of gun ownership and gun use. And then on the other side of this has been states that have implemented laws that have become more restrictive. In other words, and...

So you're seeing this at the state level because for, you know, despite the fact that Sandy Hook really did impact the whole nation, the federal government really hasn't acted on this with much effort. So it's really come down to the states to take their own initiative. So what you have is, like you said, kind of a natural experiment where you have two different groups and, you know, we can start to see how they're faring in terms of handling firearm harm.

So it's great that that evidence which shows the efficacy of restrictions is emerging. Shannon, you are taking this kind of evidence and turning it into political action. So I wonder what kind of messages you're taking from the data and pushing forwards there?

Well, I mean, I think the change came from finally having a grassroots movement that could take the data and the research being done by people like Lewis and use it to tell stories and use it to change the hearts and minds of lawmakers. Right now, that has mostly been Democrats. But when I started Moms Demand Action back in 2012, I

About a quarter of all Democrats in Congress had an A rating from the NRA. Today, none do. And that is in large part because they have data now that can back up their policies. You know, the things that Lewis was saying are pretty intuitive. If you have a state with less regulation and more guns, you're more likely to see more gun violence and more gun death. But until you have the data, it sort of becomes a war of words. And we've also seen that

happen in this country, which is we have this gun lobby, gun manufacturers. They're one of the most wealthy, most powerful special interests that's ever existed. And they have in many ways a 30-year head start of telling their data story, of creating this rhetoric and fallacies.

You know, for example, to say that somehow a gun will make you safer or that guns are used defensively millions of times a year. You know, all of these things have become part of the conversation, even though they're not true. So the work that Lewis is doing is very, very important to activists in this country because we can finally tell an accurate story. But I still think we have a long ways to go to counter the disinformation that's already out there.

So, Lewis, we've talked quite generally about this, but what are some of the really specific things that you see are helping to reduce gun violence? We've seen that there have been some that have, you know, really been instrumental, at least the data indicate that they've been instrumental in reducing firearm harm. And they range from, you know, universal background checks and waiting periods to

what are called permit to purchase licensing schemes, which means that beyond just getting a universal background check, you have to regularly apply for a license. And when you do that, you're going to have a subsequent background check to make sure that nothing has happened in the interim that would disqualify you from owning a firearm. And sometimes those schemes also have require, you know, frequent or regular firearm training requirements.

And then some other things that we've seen that have been successful have been how we deal with high-risk individuals and what can be done to either prevent them from acquiring firearms or to dispossess them of firearms if they do have them. And one of the things that we found that we're starting to find that is effective is the use of what are called extreme risk protection orders to have someone at least be temporarily dispossessed of firearms if they're considered a threat to themselves or a threat to others.

And then a couple other quick things. We've seen success in terms of regulating and restricting assault weapons and large capacity magazines, especially with regard to limiting mass shootings. And then perhaps what has been the most successful is

are safe storage laws that are coupled with child access prevention laws that make sure that, you know, if there's a firearm in the home and there are children in that home, that there are, you know, assurances that the child cannot access those firearms. So that's an example of some stuff that's worked. Shannon, I see you nodding away there. Those are a lot of data that you can take forward, but obviously you need to pick things that you think are politically expedient.

I wonder out of that, what particular stories, what particular messages you'll be taking forward? Well, that's what's so important is to have these evidence-based solutions. And I think it's important to be clear about the crisis we face in this country. Yes, Lewis and I were both impacted by the Sandhook school shooting because it was...

Truly unbelievable that 20 children and six educators could be slaughtered in the sanctity of an American elementary school and too many of our lawmakers would do nothing. But it's also important to remember that the vast majority of the gun violence in America is the daily gun violence, mostly in city centers, mostly with handguns that kills something like 120 people and wounds hundreds more every single day.

And so when you're talking about the solutions, I mean, what Lewis just went through were some very comprehensive, holistic solutions. It's not just one potential solution, right? It's not just an assault weapons ban. It's not just background checks. It's a whole host of solutions that creates a safety net. We don't even have the foundations of that yet in this country at a national level. We have it in some states.

And so, you know, with the different things that Lewis was talking about, for example, red flag laws, you know, we have the data now to show that there are incredibly useful tools for preventing suicide, preventing mass shootings, preventing intimate partner violence. And then we have the stories in the field that we can tell to lawmakers. For example, you know, before a red flag law was passed in California,

The mass shooter at UCSB, a university who was targeting women, his parents had told police that he was armed and dangerous. And the police said, basically, there's nothing we can do. We can't remove this man's guns because there's no regulation that allows us to do that. And so then we passed a red flag law because of that. And that law in California has stopped ever.

many potential horrific shootings. So when we can match the data that Lewis is creating with the stories that are on the ground, the people who have real life lived experiences,

That's incredibly powerful and that is what starts to create that shift I mentioned before where mostly democratic lawmakers now feel that they have both the data and the grassroots army supporting them to create policies that will be effective but also to vote their conscience. And you know, one of the other things that the data tells us isn't just what's working but what isn't working. Two of the things that really stand out that again we see time and time again in our studies

is that stand-your-ground laws and what are called shall-issue regimes. And just quickly, the stand-your-ground laws are the ones which say that you no longer have this duty to try and avoid violence by fleeing, but you can stand your ground and shoot. And the shall-issue is this change to concealed carry licenses, the right to take your gun out in public, from states that

may issue that license becoming this presumption that they shall issue those licenses. They can impose certain things like training requirements, but it's also harder for them to really do a deep dive into your background and then deny you

So what we're seeing is that states that have moved toward shall issue regimes and states that have implemented what are called stand your ground laws correlate with greater firearm harm, certainly with more violence in terms of like criminal violence. But also there's even some studies that show that it affects things that are not criminally related, like suicide.

So, you know, just like we can assess certain individual policies to see if they're being successful at reducing firearm harm, we're seeing, you know, the opposite too, that some are actually associated with increases in firearm harm. So Shannon, listening to all of this, are there any avenues, any data that you wish you had that might be able to help you in your campaigning? Data that perhaps some of the listeners to this might be in a position to research? Yeah.

Well, I mean, I think the data is starting to come out. As we talked about before, I think it just is unfortunately, you know, after so many years of disinformation, you know, there are these talking points when you go to state houses that they regurgitate that have been created by researchers paid by the gun lobby to support their case. And it's also why the gun lobby knew early on that they needed to quash funding for

gun safety research because the data that came out would be harmful to selling guns. And so when you go to state houses, you hear these regurgitated talking points over and over again, that more guns in more places somehow makes us more safe. That guns make women safer when we know, in fact, a gun in the home of a woman who's experiencing abuse makes them five times more likely to be killed by an intimate partner.

And so it's really just breaking through the noise and giving people the real data. And I have had, you know, one-on-one conversations with people. For example, I met this couple from Missouri once when I was on vacation and found out that they were keeping a loaded gun in between their mattresses to protect themselves, quote unquote, in their rural home. And they had toddler grandchildren running around there.

And so when I could give them the data about, you know, how many children access guns and how deadly it is and how much more likely that gun is to be found and used by this child to harm himself or someone else, they decided that they would store their guns more safely. So it's...

It takes a while, but we have seen so many issues in this country, whether it's seatbelts or drinking and driving or car seats and on and on. Like when the data catches up with the activism or vice versa, then you have change. And I do think it's just a matter of time in this country. And the editorial that's prompted this discussion, more gun regulation, less firearm harm, is now available on bmj.com. From gun control...

to fixing the NHS. A new editorial on bmj.com says that citizens' assemblies might be one way in which politicians can get the authority to change the way the NHS works.

I'm joined by one of the authors of that editorial, Rebecca McKee. Rebecca, can I get you to introduce yourself? I'm Rebecca McKee. I'm a senior researcher at the Institute for Government. And in the past, my former role, I have been involved in running citizens' assemblies in the UK. Well, welcome to the podcast. You've written an editorial for us about citizens' assemblies. Now, what are they in a nutshell?

In a nutshell, so a citizens assembly is one type of model. You get a representative group of the public in a room over some weekends, over weeks and months, and you get them to discuss topics. So things around, for example, climate change or planning or where wind farms might go or things on health.

And this is usually most successfully built into like government or decision-making processes to help inform and be part of the evidence base for decision-makers. You think that potentially citizens assembly could be

a helpful thing for the new government in the UK to do to fix or to tackle the problem of the NHS? Yeah, I think it's a very interesting moment and so it feels like there is an opportunity to do things differently. Now the health mission, as I understand it, does recognise that health is more than the NHS.

And so where we're thinking about social, commercial, political, environmental, all of those different determinants of health, they all do come into play. And with the health mission, it seems like compared to some of the other missions, we actually don't really have too much of a shortage of evidence to inform the policy options. And we do to a large extent kind of know what's going wrong, but also know that fixing the problems is going to require bold action and some really difficult decisions.

And the Institute for Government where I work, we've done a lot of work on policymaking. And we know that policymaking often comes up against the same barriers time and time again. So things like churn, things like a lack of evidence-based policymaking, things going into the too difficult box, or often we see that the people who are impacted by policy are rarely included. And I do think that this is a potential where citizens assemblies could come in. So

providing decision makers with a set of priorities or a set of policy recommendations that deal with kind of the trade-offs as part of their evidence base I think this really could be a great opportunity to try and set a long-term agenda I mean it's going to be it could be one part of a longer wider process but it really does seem like this this now could be could be a good opportunity.

Now, we've just heard from our previous guests about gun legislation in the US and the absolute failure of government to tackle that problem.

Is that the kind of thing that would be amenable to a citizens' assembly? Yeah, so it's tricky because there are definitely instances where we have seen citizens' assemblies that have been run on polarising topics on same-sex marriage and abortion in Ireland. We ran one on Brexit that was a research project, for example. So we know that they can be used on polarising and contested topics.

Using my limited knowledge of gun control policy in the US, I would say that there are some considerations that you really have to take seriously when you're running a citizens assembly. Some of the things you have to think about are how you run it and who runs it, how you protect the independence of the process, how you protect participants from things like lobby groups.

And whether you have genuine buy in from decision makers, so the government, that they are going to listen in some way to the recommendations and that they are going to potentially want to take action. They want to hear from this. I would say that's going to be very tricky. And that would be the kind of difference between some of the more polarizing topics that have been dealt with elsewhere. And that one, I think.

The other bit of the discussion we just heard about gun control was the use and the importance of having good evidence, going into the debate, clarifying positions, busting myths. And I think all of our listeners who interpret evidence for a living know how difficult that can be for people who've been trained to do this. So within a citizen assembly, how do

do you ensure that good evidence goes into the process and is understood and synthesized by the group? So there's kind of a whole process that goes into it. One of the things is that we work with the experts who come in to kind of hone their communication style.

in order to make sure that they are, they themselves, and as a former academic, I feel like I can say this, but some people aren't very good at communicating their findings to people. So we work with them to make sure that they can do that because that helps to create an even playing field so that participants aren't more swayed by somebody who is just better at explaining their work to people that don't have a background in it.

The other thing we do is we create briefing packs which again are like really excessively written documents that outline a lot of the evidence and I know we did this on the citizens assembly on climate change which we ran in 2020. We also have Q&A sessions so again we will have different experts in the room at different points and they're then

questioned like at the tables so tables of like eight to nine members uh of the assemblies and they'll spend time with them like questioning and um asking them and challenging them to to kind of really get to grips with some of the things and and it's really interesting some of the questions that people ask that often I guess you wouldn't necessarily think

And actually, on the whole, the things that I've worked on, you know, the expert leads that we've worked with have been really impressed with the kind of questions that people are able to come up with and people's grasp of all of the technical details and lots of opportunities for people to tell us if they don't understand. And, for example, in between weekends, if people have questions, we then send those over to the experts and we'll then respond.

basically collect all of those answers and send them back to everybody and I think there's quite a lot of this particular detail we then make space to cover that off. You've been listening to Rebecca McKee from the Institute of Government and you can read her editorial which argues for greater use of citizens assemblies to fix the NHS on bmj.com and that's it for this episode.

Next time, we'll be picking up on our climate change issue and how climate fiction, cli-fi, can help us tackle global warming in the real world. That will be available on Apple Podcasts, Spotify, or wherever else you get your podcasts from.