Guns Part 5: The Footnote

2023/9/28

Revisionist History

AI Deep Dive AI Chapters Transcript

B

Babak Sarani

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Elizabeth Tong

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James Gundlach

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Malcolm Gladwell

以深入浅出的写作风格和对社会科学的探究而闻名的加拿大作家、记者和播客主持人。

Malcolm Gladwell: 本集探讨了美国枪支暴力问题，特别是医疗保健系统在其中的作用以及种族差异。通过对一篇犯罪学论文的脚注以及对相关人士的采访，揭示了医疗资源分配不均、种族歧视等问题如何导致非裔美国人社区的枪支暴力受害者死亡率更高。 James Gundlach: Gundlach教授分享了他收养街头青少年的经历，其中一个孩子Brandon Young在他家中被枪杀，这与他之前发表的关于阿拉巴马州枪支暴力与医疗保健关系的论文中的发现相呼应。他讲述了救护车到达现场迟缓，以及这可能与种族歧视有关的经历，这进一步突显了医疗保健系统中存在的种族不平等问题。 Babak Sarani: Sarani医生作为创伤外科医生，强调了在枪伤治疗中时间的重要性，以及不同受伤部位和出血情况对患者存活率的影响。他解释了医护人员如何在现场对某些枪伤进行临时处理，从而提高患者的存活率。 Elizabeth Tong: Tong医生介绍了芝加哥枪支暴力与医疗资源分配不均之间的关系，特别是南区长期缺乏一级创伤中心导致非裔美国人社区的枪支暴力受害者死亡率更高。她指出，医院不愿在贫困社区开设创伤中心，因为这些社区的患者通常没有医疗保险，导致医院的报销收入减少。 Malcolm Gladwell: 本集探讨了美国枪支暴力问题，特别是医疗保健系统在其中的作用以及种族差异。通过对一篇犯罪学论文的脚注以及对相关人士的采访，揭示了医疗资源分配不均、种族歧视等问题如何导致非裔美国人社区的枪支暴力受害者死亡率更高。

Deep Dive

Pushkin. I'm Malcolm Gladwell, and I'd like to take a moment to talk about an amazing new podcast I'm hosting called Medal of Honor. It's a moving podcast series celebrating the untold stories of those who protect our country. And it's brought to you by LifeLock, the leader in identity theft protection. Your personal info is in a lot of places that can accidentally expose you to identity theft.

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Lenovo Pro is a partnership that will help you understand and utilize tech trends. It works with you over time to take advantage of offers and resources that are right for your business. So, to join Lenovo Pro, visit Lenovo.com. That's Lenovo.com. I read footnotes. I always have. Perhaps it seems like good manners to read everything someone else has written for you, like cleaning your plate when you're a kid.

Or maybe it's because a footnote is where you put the bit of information that doesn't quite fit the main story, but at the same time is too important to leave out. And to my mind, the thing that is important and doesn't fit is often the most important thing of all. So I read footnotes, and occasionally that leads me somewhere entirely unexpected.

Like the footnote at the very end of a paper in the Journal of Criminal Justice entitled Damned Upon Arrival, Volume 23, Number 4, Pages 313 to 323, 1995. Lead author, Penelope J. Hanke. Second author, James H. Gundlach. It made me go all the way to a little town in Alabama.

to have the man who wrote the footnote explain to me, 30 years later, just what it meant. Could you do me a favor? Can you read that, read the footnote for me? Small print. At 3.02 a.m. on September the 23rd, 1994...

A little over a month after Dr. Hanke and I submitted this article to the Journal of Criminal Justice, a death following the pattern described in this article literally stuck home. J. Brendan Young III, age 17, was shot in the back with a 12-gauge shotgun and killed in my house in a predominantly black part of Rural Macon County, Alabama.

My name is Malcolm Gladwell. You're listening to Revisionist History, my podcast about things overlooked and misunderstood. This episode is about the death of Brandon Young. James Gundlach lives in Shorter, Alabama, a little town just south of Tuskegee, along I-85.

Some parts of Alabama are wild and hilly. This is the other side of the state, flat, swampy, pine trees, Macon County, one of the 18 counties that make up the Black Belt of Alabama, where the cotton plantations were in the days before the Civil War.

Gundlach lives with his wife in an 1840s plantation house, a doctor's house. The old slave quarters are in the basement, directly below the old surgery, so the slave stove could heat the doctor's offices during the winter. Two enormous Anatolian shepherds pad around, presenting their giant heads for attention. The house looks untouched from the 19th century. There's an abandoned truck in the backyard. I grew up tough.

I was a World War II baby, and my father came back from the war mentally messed up, and he became an alcoholic. And we lived on a farm, and he would take off on a drinking bridge, taking my mother with him, and be gone for days. Gundlach is tall, stooped, wisps of white hair. He moves and talks slowly. That continued on when I was 11. We ran out of food.

and I saw this big flock of blackbirds, crows. And so I took the 12-gauge shotgun and my brother and I, we went up and snuck up on them. And as soon as they started flying, I went and I got two shots off. And as I was talking to my brother, reminiscing about this, he said, "Yeah, and you said your whole shoulder hurt so much you made me go pick up all the dead birds."

But we sat there, started the fire, stripped and dressed out the birds and on a stick roasted them just to be able to have food. He escaped home by enrolling in the army, went to college, then graduate school, then to Alabama and taught sociology at Auburn University. One time he caught a huge cheating ring going on with teachers in his department and football players and blew the whistle. Made the New York Times. In one of the most football crazed states in the country,

He went after football. Today's the 28th day of my 81st year, so I'm on the old side. And six months after I retired, I had an encephalitis infection of the brain. And I survived it when I was 66, which is quite rare. But when I came to from it in the hospital, I had company, but I couldn't think of...

I couldn't think of words to say what I wanted to say. He forced himself to go through the alphabet, A to Z, counting all the words he knew that began with each letter. He came up with 196. My first conclusion was that I was essentially brain dead. I may as well put myself down. Then after I thought of it, I thought, well, the way I measured it meant that I'm not completely brain dead, so I just decided against the suicides.

Slowly, he recovered, built himself back up. He was working on a new paper when we spoke, an analysis of health insurance status and mortality rates. By the way, you will hear all kinds of strange noises in the background as you listen to Gundlach talking. Let me go turn that thing off. My wife always leaves it unbalanced and it makes an awful lot of noise.

And if I'm going off on tangents that you're not interested in, why don't we actually... Some of what you're talking about now feeds into what I want to speak to. So why don't we start with the stuff that was interesting to me the most, which was... I read that Damned on Arrival paper, and I just thought it was absolutely fascinating. And I wanted to kind of talk to you a little bit about that, and that'd be a good place to start. Okay. Okay.

We talked a little about the paper, and then James Gundlach went off on what seemed like one of his tangents. Although, as I found out, it wasn't really a tangent at all. It was about the time back in the early 1990s when he got a call from his brother. His brother's daughter had run away. The police called him and asked him why he hadn't canceled the missing child. He said, well, she's not back home. They said, well, she's never missed school.

She worked out a system by which she was just staying with friends overnight in sequence and just avoiding going home by living out in the world and still going to school. Gundlach took his niece in. She was about 14. So was his daughter. Now he had two teenagers under his roof.

She eventually decided that we were such good parents that she found a couple of street boys had been thrown out of their own homes and we ended up taking them in. They were living in Montgomery then, and parts of the city were full of gangs. The Bloods, the Crips, the Disciples. Word got out that the Gundlach's house was a place of refuge. One time, we had this big lizard, and the lizard got out. So I was going around looking for it.

And I looked under the bed and there was this boy. And I looked at him and he said, "I guess you want to know why I'm here." And he was just kind of a temporary quasi street kid. He was sort of staying in our house to be out off the street and stuff without having contact with the adults in the house.

I sat in a small chair next to Gundlach's desk as he talked about the kids he took in. Boys in gangs, boys living off the street, who stole car radios to stay alive and drank cheap liquor to stay warm at night. What is it about you, do you think, that led you to take in so many of these kids? Well, I think it was rooted in the time that our parents left us alone on the farm, that

I can really relate to kids not having parental support and sufficient support and other kinds of things. One of the kids they took in came from a little town called Valley in the northern part of the state, an old textile town. He was 17. He was involved in one of Montgomery's many gangs, but he was looking for a way out. His name was Brandon Young. How long did Brandon live with you?

Probably only about six months. Yeah. But you got to know him well. Oh, yeah. At first, he was very, you know, reserved and suspicious and other such things. But, you know, as he got to know me and stuff, he opened up and would talk about things and

And then James Gundlach started talking again about the paper he wrote with Penelope Hankey, Damned Upon Arrival. I'm Malcolm Gladwell, and I'd like to take a moment to talk to you about an amazing new podcast I'm hosting called Medal of Honor.

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whether you're a startup or a mature business. So, to join Lenovo Pro, visit Lenovo.com. That's Lenovo.com. The number of homicides in any community is a combination of two completely unrelated variables: the number of people victimized by acts of violence minus how good a job the medical system does at saving the lives of those victims.

And a lot of times, what a murder rate really tells you is how good your doctors are and not how safe your streets are. This is the idea we explored in the previous episode. But there's a twist on that observation, a really important twist, which the people who treat gunshots for a living have known about for a long time. So I'm assuming over the course of your career, you have treated innumerable gunshot wounds. Unfortunately, true.

This is Dr. Babak Sarani. He's a trauma surgeon at George Washington University Hospital in Washington, D.C. If you get seriously injured by a bullet, you get taken to a trauma center, more specifically, a level one trauma center.

which is a self-contained 24-hour facility equipped with everything necessary to treat traumatic injury. General surgeons, orthopedic surgeons, neurosurgeons, plastic surgeons, anesthesiologists, ER docs, radiologists, nurses with the right qualifications, on and on.

Level 1 trauma centers cost hundreds of millions of dollars to build and operate. They're relatively rare. DC has 13 hospitals, but only four level ones. One of those is at George Washington. Sarani is the chief trauma surgeon there. Do you know how many, roughly speaking? Oh my goodness, I would think probably by now, the number of gunshot victims I've seen personally, I've been in practice since 2005.

I would venture mystical at will 500 plus. Wow. Yeah. And you weren't even there during DC's darkest years. Correct. Yeah. Correct. I wanted to talk to Sarani about time because trauma surgeons are obsessed with time. There's a phrase common in their world, the golden hour. If you get shot, they really want to have you on the operating table as soon as possible. That's why we pull over for ambulances.

Talk a little to me about time. You said EMS tends to get there within 10 minutes and you tend to get to the trauma center between 20 and 45. What's the difference between 20 and 45? What happens in that extra period of time that would diminish someone's chances of survival? Yeah, I think it depends on where the injury is. You know, if you've been injured in the abdomen and it hits your intestine, honestly, nothing will happen between 20 and 45 minutes. That's plenty of time.

But if you're bleeding, specifically speaking, if you're bleeding, then every minute that goes by is, you know, the value of that is plutonium. Like, for example, if you take a bullet to your liver, the liver is a maze of blood vessels.

Making the liver of all things stop bleeding is exceedingly difficult. You know, kidney, I can take it out. You have two kidneys. Spleen, I can take it out. You don't need a spleen. I cannot take out your liver. You need a liver to live. And so I'm obligated to try to repair it while it just continues to bleed. When we spoke, Sirani had just treated someone who had taken a rifle shot to the liver.

The reason he's alive, and we'll take some credit at George Washington, but honestly, one of the big reasons he's alive is the paramedics. They completely scooped and ran with this guy. I think their entire scene time was like 10 or 12 minutes. And they just hightailed it to the trauma center. When he showed up on our doorstep, you figure by now it's been 20, 25 minutes at the most from the moment of wounding to arrival to the trauma center. He was probably...

five to 10 minutes away from dying. He was at the extreme end stages of shock. Or what about a bullet to the lungs? A paramedic can actually treat a gunshot wound to the lung. They can temporize that person very nicely. So do that. How do you temporize someone who's had a gunshot wound to the lung? So when you have a gunshot to the lung, assuming it has not hit a blood vessel, assuming you're not bleeding, all you have is a gunshot to the lung, which is, believe it or not, really, really common.

The problem is you have air leaking from your lung and that air is accumulating inside the chest. As that air collects more and more inside the chest as it's leaking out of the lung, it'll create a lot of pressure in the chest and it'll cause, it'll alter the blood flow to your body.

So the paramedic can simply put a needle inside your chest, believe it or not, just like literally insert a needle through your skin into your chest. And it's like popping a balloon. It'll allow that air that's accumulating to decompress. And that's all you have to do. That will buy the person then tens of minutes, if not more, to get to the trauma center to allow us to then fix the issue at hand. But that's a paramedic skill. Absent that intervention,

That would be a fatal event. Correct. Just to linger on this time question for a moment. So if I have a gunshot wound to the chest and I have exactly happening to me what you just described, how much time do I have without an EMS's intervention? Half an hour? Yeah, probably about half an hour or so. I mean, plus minus. But yes, I would think so. So let's think through the logic of this.

A city or country's homicide rate is heavily dependent on how good its medical system is at treating gunshot wounds. And what determines how good a medical system is at treating gunshot wounds? At least in part, it's how quickly a gunshot victim can get to a level one trauma center. Okay, second question. And in this case, let's use Chicago as our example.

classic big American city. Chicago absolutely confirms the theory that proximity to a trauma center matters. According to a big study done a couple years ago by the epidemiologist Marie Crandall, if you live more than five miles from a level one trauma center in Chicago, you had a 35% higher chance of dying from your wounds than if you were shot less than five miles from a level one.

So, here's the second question. What determines how quickly you get to a trauma center in Chicago? Is it a random fact, like whether there's an ambulance nearby when you get shot, or how bad the traffic is that day on the way to the hospital? Or is there a pattern to who lives within five miles of a level one and who doesn't? A physician at the University of Chicago named Elizabeth Tong set out to answer that question a few years ago.

What do you find in Chicago? And so we found that black majority census tracts were disproportionately in these trauma deserts. A trauma desert, by the way, is what ER docs call places that are a long way from a level one. That racial disparity was essentially...

a very large, approximately a sevenfold increase on the South Side in Black communities. Wait, so explain the sevenfold. The racial disparity between what and what is sevenfold higher? The racial disparity between Black-majority census tracts and white-majority census tracts. Is 7X? Sevenfold. Sevenfold. Wow. Wow.

For a period of 30 years, between 1991 and 2018, the South Side of Chicago didn't even have a level one trauma center. So if you got shot on the South Side, and by the way, the South Side is the area of Chicago where you're most likely to get shot, the ambulance had to take you all the way across the city, uptown to Northwestern or Cook County or west to Advocate Christ Medical Center, miles away. Now, why did the South Side go so long without a trauma center?

because it makes no sense for any hospital to open one on the South Side. Treating gunshot wounds, serious ones, is incredibly expensive. And the typical gunshot victim in Chicago is a young black man from a poor neighborhood. And young black men living in poor neighborhoods in Chicago typically don't have health insurance. Or they're on Medicaid, which reimburses at a fraction of what private insurance does.

The euphemism used in the healthcare world is payer mix, which refers to how many of your patients come to you blessed with private coverage. Opening a trauma center in a bad neighborhood messes with your payer mix deeply.

Which is a paradox, right? The point of a trauma center is to be closest to the places where people are getting shot. But if you put your trauma center close to the places where people get shot, your payer mix will go to hell in a handbasket. And you won't be able to afford to run your trauma center. So you put your trauma center as far away as possible from the people who most need your trauma center.

As I said at the very beginning of this series, the way America deals with gun violence is bonkers. We have a misaligned health care system. Yeah. What's the simplest way to realign it? I mean, I think the simplest way to realign it is nationalized health care. What she's saying is that if everyone has the same insurance, like they do in Canada or Europe, then hospitals don't have to worry about payer mix.

You can put your trauma center where your trauma center makes the most sense and not worry about how much your patients will pay you. It's funny you say this. So I'm not someone in the medical world. Yeah. But I'm certainly sort of familiar with arguments around national health care. It had never occurred to me until just now, listening to you, that if one of the consequences of national health insurance is that hospitals would look different, would do different things, and would be in different places.

Yeah. I mean, the idea would be that under a nationalized health care system, we could be a little bit more thought out in the planning of health care. We're essentially taking the market forces out of that. And we're saying, let's plan this the way that it should be planned. And let's incentivize hospitals appropriately to essentially be able to care for their patients at the level of care they need to be cared for. Yeah. Or let's not penalize people

who want to serve the sickest population. Exactly. Which is what we're talking about. Yeah, exactly. Hospitals aren't even just not getting incentivized, they're actually getting penalized. And so that's the problem in terms of our healthcare financing system. Yeah, yeah. The way it is. Yeah. Such a kind of like, it's so weird that you would penalize somebody for essentially for doing the job in the best way, right? The whole reason people go into medicine is to help the

sickest people. Absolutely. But the system is set up such that if doctors do what they went into medicine to do, the institutions they work for are penalized. Yeah. Yeah, absolutely. And so there actually has been a lot written recently about the moral injury of our healthcare financing system and how it really does make a lot of healthcare workers feel incredibly demoralized at the end of the day.

And, you know, I mean, that's just that's not good for anyone. Final question. And here we come to the twist that the people who treat gunshot wounds think about all the time. A, it really matters how close you are to a trauma center. B, in a place like Chicago, black people for years were really, really far from a trauma center.

So how much of the reason that black people have such a high homicide rate is just a function of the fact that we're not doing a terribly good job of saving the lives of black people after they've been shot? It's an uncomfortable question. And one of the very first scholars to venture down this path were Penelope Hanke and James Gundlach in the Journal of Criminal Justice, Volume 23, Number 4, 1995.

Damned upon arrival. The idea behind the paper was ingenious. A sociologist at Auburn named Alan Shields had assembled a database of homicide offenders from Tutwiler Prison, the all-women's prison just north of Montgomery. Not an especially nice place. Tutwiler's primary distinction was that it was once named to the 10 worst prisons in America list. So Gundlach and Hankey looked at all the murderers in Tutwiler.

and divided them by race. First, the white murders. There were 47 people victimized by white women who died instantly. No amount of medical attention would have saved them. Headshots, bullet to the heart. And a roughly equal number who were dead on arrival. Those who could, at least theoretically, have lived if they'd gotten medical attention sooner. The ratio of killed instantly to dead on arrival was essentially one-to-one.

Then, Gundlach and Henke looked at the victims of black murderers. What was their ratio? It wasn't one-to-one. It was way out of whack. There were many, many more victims who died on the way to the hospital, and also a far higher percentage who died at some point after being admitted.

What the study suggested was that a big chunk of the difference in homicide rates between blacks and whites in Alabama had to do with the quality of health care given to their victims, not the violent tendencies of the people who attacked them. Here's the key conclusion.

Although this is by no means a definitive study of the issue, the strength of the findings is striking. The Tutwiler prison data suggested that almost one-fourth of the African-American female killers might not have been in prison for the killing had their victims received the same transportation and medical care as their Caucasian counterparts.

The study covered 468 African-American murderers at Tutwiler. So that's 113 people who wouldn't have been convicted for homicide if their victims had received the same medical attention as white people. They'd have been convicted on lesser charges, like aggravated assault. They wouldn't be murderers. And at the very end of the paper, Gundlach and Hankey give us a little hint of what they think was going on in Alabama.

One anecdote related by a female inmate at Tutwala Prison is particularly revealing. I'm reading from the final paragraph of the study. Having seriously wounded a male in an argument, she drove him to the doctor's house. At that time, she was advised by the maid that the doctor was having dinner and could not be disturbed. The man died. The assailant and victim were African American. The doctor was Caucasian.

Hankey and Gundlach presented an early version of their paper at the American Society of Criminology meeting in Phoenix in the summer of 1993. And while Gundlach was putting the finishing touches on the paper, Brandon Young moved into his house in Montgomery. I'm Malcolm Gladwell, and I'd like to take a moment to talk to you about an amazing new podcast I'm hosting called Medal of Honor.