I enjoyed a series of conversations with Dr. Céline Gounder, epidemiologist, infectious disease specialist, and member of the Biden-Harris Transition COVID-19 Advisory Board. Dr. Gounder is also the host and producer of two vital podcasts: “American Diagnosis,” on health and social justice, and “Epidemic,” on infectious disease epidemics and pandemics. Follow Dr. Céline Gounder on Twitter at: @celinegounder
[Note: this interview was edited for clarity and length]
Dr. Caroline Light (CL): You’re trained as an epidemiologist, as you put it, “a disease detective.” How is epidemiology a useful lens for interrogating the root causes of gun violence?
Dr. Céline Gounder (CG): Many people do not understand what epidemiology means. They think it’s the expertise of epidemics, which is not accurate. Epidemiology can be divided into quantitative and qualitative. Quantitative epidemiology is the mathematical study of the occurrence of disease. In the case of infectious diseases, that might mean transmission dynamics. In the case of noninfectious diseases, that might be risk factors that predict diseases.
And to take the case of gun violence, medicine has much to contribute because gun violence follows patterns similar to infectious diseases. Gary Slutkin, an infectious disease trained epidemiologist, has done important work here.
As with diseases, there are patterns of contagion with violence. We might think of the dynamic of a host pathogen ecosystem. With violence, you can apply a similar lens. Consider malaria, for example: you have the person who’s the host, the mosquito that transmits malaria, you have P. falciparum, the malaria parasite, and finally the ecosystem in which the disease gets propagated.
Similarly there are people who are infected with violent behavior, there are guns, which function as perhaps the mosquito, and there’s also the socioeconomic, geographic, and the cultural ecosystem in which gun violence is propagated.
It’s a useful lens because – too often in the case of gun violence – we oversimplify the problem and the solutions. Like the saying, “guns don’t kill people, people kill people.” It’s obviously more complicated, a mix of multiple factors. To prevent further loss of life, you need to resist over-simplification, as in “it’s the guns,” or “it’s the people,” or “it’s criminal behavior.” We should consider all of the above.
From an infectious disease perspective, many assume that emergency room doctors know everything about healing, and they don’t. Their job is to stabilize a wounded person, but we need to consider what happens after the patient leaves the ER. A patient with an abdominal firearm wound will most likely end up with an infection. I had a patient in Baltimore who got shot in the leg while being chased by police. He ended up with chronic osteomyelitis, a bone infection. These infections follow the gun wound patient after they leave the ER. So doctors spend a lot of time with gunshot wound victims, not only in the immediate aftermath of their injury, but over the course of their lifetime as survivors.
CL: I appreciate the way you bring the quantitative and the qualitative data together in your public-facing work. You bring multiple narratives and perspectives into your podcast “American Diagnosis,” and the third season is on gun violence (after prior seasons on the opioid overdose crisis and on mental health). What inspired you to focus on guns?
CG: It had been on my mind for a while. Opioid use disorder, mental health issues, and gunshot wounds are common among my patients. Abraham Verghese addresses this really well in My Own Country, where he talks about serving communities in rural Tennessee where patients with HIV were considered “pariah patients.” Then as now, infectious disease doctors have had to become “jacks of all trades.” Many victims of gun violence are not insured or are marginally insured. So we find ourselves having to treat issues that are outside our scope of practice, and we have to advocate for our patients who are dealing with these issues.
CL: Reflecting on your series on gun violence, what are some of your key take-aways? Were there any surprises or epiphanies you experienced producing these podcasts?
CG: I think the intersectionality of race, gender, and guns was where I learned the most while researching those episodes. There’s an “American Diagnosis” episode – number seven in season three – “She’s Got a Gun,” where I interviewed you and Mary Anne Franks, along with Callie Adams, a woman imprisoned after shooting her husband in self-defense. Women – especially women of color – experience difficulty finding legal protection after they defend themselves from violent husbands and boyfriends.
I also became fascinated with the “instrumentality of guns,” which helps us understand different means by which people die by suicide. Three examples are guns, gas, and pesticides. Depending on the context, the “instrumentality” approach asks: who is going to have easier access to what lethal means of taking their own life? We discover that Access is differentiated by race, gender, socioeconomic status, and geography. In terms of gas, English women were using gas stoves to cook in the mid-twentieth century, and many died by suicide using gas. Thus changing the type of gas used in English ovens resulted in a drop in suicides.
In rural farming communities in South Asia, farmers, who are mostly men, have access to lethal pesticides. When a crop failure results in economic disaster and inability to support their families, many farmers may turn to suicide using pesticides, which are readily available to them, which has led to a growing movement to ban such chemicals.
Similarly, in the U.S., historically white men are more likely to be gun owners than women and non-white people, and guns are not cheap, so it’s easier to gain access if you have the means to purchase a gun. Gun suicides, which constitute a majority of all gun deaths, disproportionately affect white men.
CL: The kind of public-facing work you’re doing requires a deep engagement with knowledge and experience from outside of academia. Where do you locate expertise in gun violence and gun violence resistance?
CG: It’s very much an expertise based on lived experience, especially in communities of color, especially among women who experience intimate partner violence. For intimate partner violence and gun violence, the number of researchers in that space who have experiential knowledge and who are seen as academic experts is a very small group.
CL: I started looking at the intersections of gun violence and intimate partner violence, and specifically when women defend themselves against their largest statistical threat – not a criminal stranger, but their husband, boyfriend, or ex – they are more likely to go to prison. What do you think accounts for the lack of research on that intersection of criminalization and armed self-defense for women and Intimate Partner Violence (IPV)?
CG: I think one way to account for this is just how many women are in that space. How many of them have both had personal experience with IPV and feel empowered to be in a position to do this research, or first pursue and obtain academic training in order to begin doing so?
We should consider why people decide to study particular issues. As an academic, a lot of it’s driven by your own personal experiences and what resonates with you, what you’re passionate about. And so if you are a victim of violence, you’d face additional challenges like economic and social instability, making it harder to obtain academic training and resources to support your research.
There’s also a point where we can think about the overlap of the pandemic and the epidemic, the surge in gun purchases and quarantines, and people having to stay home and shelter in place with their abusers.
CL: It looks like some public health data is showing increased incidents of intimate partner violence, but whether guns are involved is hard to track. It’s one of those data points that is really elusive.
CG: What we are seeing in the COVID context and the gun context is that women are disempowered, lacking resources, not having control over their environment, whether through risk of infection, like what we saw at the beginning of the pandemic, in which essential workers who were often women lacked personal protective equipment. Adding guns to an already volatile circumstance increases the risk of death and injury.
One thread is thinking about how race and gender affect how people are put at risk. Essential workers in these caregiving professions are disproportionately women and women of color, concentrated in lower paying, and really high touch service areas. Similarly, women are more vulnerable to violence if they’re quarantined with their abusers. So there is a dovetailing of these vulnerabilities in a context of widespread gun deregulation and inadequate public health measures.
CL: How does having more unregulated guns in circulation, in the hands of largely unregulated civilians affect public health and safety? For example, I’m thinking of so-called “constitutional carry” measures that allow people to carry guns without a license or any gun safety training.
CG: I think part of it concerns your sense of security. How do different people feel navigating public spaces? I think there is widespread anxiety especially among socially vulnerable populations. I have friends, a gay couple, who just moved across the country. While driving across they made a point of not stopping in certain states. In fact, they mapped their routes by looking at which states or counties voted for Trump in 2016 and in 2020. In those counties, they did not stop for gas or food or anything. They made a point of this, because these are places where you’re more likely to encounter homophobia and people are more likely to carry guns.
This reminded me of the “green book,” how African-Americans used to plan their road trips to stop only in spaces of relative safety. The wide circulation of guns has a very real impact on how people navigate spaces, and it’s going to affect some people more than others.
In terms of guns, how likely is an African-American man to carry a gun in his glove box, to protect himself on a cross country road trip? He would have to consider the chances that he’s going to get stopped by a cop and be placed in danger. These considerations affect one’s ability to quite literally navigate the country or risk becoming a target.
As we’ve seen with Philando Castile, there’s a profound double standard when it comes to your ability to exercise your right, to protect yourself, and whether or not guns provide true protection or not. There is a differential both in how the gun presents a danger to you and how you’re able to use it to defend yourself against danger.
CL: Philando Castile was a law abiding “good guy” with a gun, and his death illuminates what you were saying before. There’s a feedback loop in which anxiety produces a desire to have a gun to protect yourself in a world that doesn’t even recognize your right to protect yourself.
CG: It exemplifies how some have the right to protect themselves with guns and others do not. On the one hand, you feel even more threatened. And then even if you try to exercise the right to defend yourself, it can backfire quite literally, so it’s a catch 22. What are you supposed to do?