This transcript has been edited for clarity and length.
In recent years, the healthcare community has struggled as politics invaded certain medical issues. One such issue is gun violence. SoundPractice’s guest for this episode is uniquely qualified to discuss the individual and public health consequences of gun violence in the United States.
Mike Sacopulos: My guest today is Dr. Megan L. Ranney. She is the dean of the Yale School of Public Health, the C.-E.A. Winslow Professor of Public Health for the Yale School of Public Health, and a professor of emergency medicine at Yale School of Medicine. Dr. Ranney has been elected to the National Academy of Medicine. Dr. Megan Ranney, welcome to SoundPractice.
Megan Ranney, MD, MPH, FACEP: Thank you. It is a joy to join you today.
Sacopulos: You are an emergency medicine physician and public health researcher. And you recently became dean of the Yale School of Public Health. Can you share a bit about your career journey? What brought you to medicine, to public health, and to your current position as a dean?
Ranney: Thank you. It has been a winding journey. It is one of those things, as I am sure you hear often, where when you look back, you can make a linear story out of it, but along the way, it was full of twists and turns.
I made my way into medicine by being a Peace Corps volunteer. I thought that I was going to work overseas in foreign aid or journalism. I spent two and a half years in West Africa at the height of the HIV/AIDS epidemic and realized that I really wanted to be able to treat patients as well as describe and act on systemic problems.
I went from there to med school and fell in love with emergency medicine, which I will unabashedly say is an incredible specialty within the house of medicine. It is team-based, it is the safety net of the American healthcare system, and it really is the canary in the coal mine for every public health problem out there.
Emergency medicine is really a tremendous space. And the people who dedicate their careers to working in the emergency department, whether it is doctors, nurses, social workers, are some of the most incredible practitioners out there. I loved my emergency medicine training.
While in emergency medicine, I went the opposite way from where I had gone in the Peace Corps, where the structural problems became so apparent to me. I very quickly got frustrated with taking care of patients with utterly preventable problems and equally frustrated with sending people back onto the streets or to their homes, knowing that they were walking back into the same situations that had landed them in the emergency department in the first place.
And that is what then had me go and do public health training. I have spent the last 20 years as a clinician and as a public health researcher and advocate and activist and found my way into being dean almost by accident.
My north star, my driving force in my career, has been looking for a way to make the most difference in the health of other humans, whether on an individual level, when I am working as a doctor, or on a population level through public health work. Right now, at this moment, being dean, especially at the Yale School of Public Health, is just an incredible opportunity to think about how we improve the health of populations and how I improve the work and the success of my colleagues in clinical medicine.
If you talk to any physician or nurse right now, you’re going to hear about the frustrations with the fact that we are the fingers in the dike, holding up society, and that so much of our time as clinicians is spent dealing with social problems and with inadequate resources to address them. By being a dean of a school of public health and creating science- and systems-level changes, I can, hopefully, of course, improve the health of populations, but also make my fellow clinicians’ jobs a little bit easier and more fulfilling.
Sacopulos: One of those issues that you must have seen and grappled with in the ER is gun violence. And you are, as I mentioned, a national expert on this problem. Gun violence is a public health problem. Can you tell us what you mean by this? And what exactly is a public health approach to this issue?
Ranney: Yes. Well, you and I are talking right after the latest tragedy in Georgia, the shooting at the high school in Apalachee, which, like most school shootings, was utterly preventable. I think I, like anyone else in the house of medicine, have taken care of countless victims of gun violence, generally victims of community violence. We know that Friday and Saturday nights are going to be the “knife and gun club” in emergency medicine.
We choose our residencies in part based on the volume of penetrating trauma that we’ll care for as residents, knowing that we need that training for when we go out into an attending job. At one point early in my time as an attending, I had this realization that the violence that was bringing people to my door was just as preventable as heart disease, suicidal ideation, or any of the other things that bring people to the emergency department for care.
At that point, I am going back again almost 20 years now, people didn’t really talk about violence as a public health problem. And I was, in fact, told by mentors to stay away from the issue, that it was a third rail for academic medicine and public health. It was not a career path that would lead to funding.
However, I was not willing to accept the patients coming through my door as something that was a foregone conclusion. I started to create coalitions with other physicians, nurses, and, of course, public health researchers, survivors, and social workers, to try to create a path forward. And, really, that path forward — applying a public health approach to the problem of gun violence — is quite simple.
The public health approach is four standard steps that we apply to myriad health problems.
First, you define the scope of the problem. How common is it? Second, you examine risk and protective factors. What puts someone more at risk? What protects them? Then, you design interventions that would make a difference. And when you figure out what works, you scale it up.
That is the approach that we take for heart disease. It is the approach that we took to COVID. And we can apply it to injuries as well. We have decreased car crash deaths by over 70% over the last few decades by applying that standard public health approach. We have been successful in some countries in reducing suicide deaths by applying the public health approach, although not here in the United States.
Unfortunately, we have not been successful in reducing suicide deaths in the U.S., largely because we have not talked about the problem of guns. Two-thirds of gun deaths in this country are gun suicides, and so that is just as much of a part of the discussion about gun deaths as gun violence or these school shootings.
So, I started advocating for the public health approach and have slowly but surely, over the last 20 years, succeeded in creating coalitions of researchers and getting federal funding reinstated in 2020 for the first time in 24 years. We have created a research society for the prevention of firearm-related harms and are slowly but surely creating evidence to inform what we do.
When you approach this as a health problem, yes, of course, it is political. All of medicine and public health are political, but it takes away some of the rhetoric about us versus them. Instead, we can operate based on actual data about what is most likely to work and create partnerships and coalitions to put that in place.
There have been some terrific successes over the past few years. Unfortunately, they are not coming fast enough for the 40,000 people who lost their lives last year or for those kids and teachers in Georgia just a couple of days ago.
Sacopulos: I think that the average American probably views the school shooting as the manifestation of the problem of gun violence and not the 2 out of 3 gun deaths being suicide. Isn’t the first challenge defining the problem?
Ranney: Yes. Absolutely. That is the first step in the public health approach: defining the problem and getting agreement on what the problem is. That’s foundational. Again, that is the beauty of taking a public health approach instead of a criminal justice approach; we are not waiting until someone needs to enter the criminal justice system. Instead, we are describing the patterns of death, but also the patterns of injury and the patterns of health harm for folks who may not ever be touched by a bullet.
A recent survey by the Kaiser Family Foundation reported that 54% of American adults say that they or someone in their immediate family has been present at a shooting or has been shot. It is an astounding statistic. And there is a margin of error, so say it is 20% less than Kaiser Family Foundation estimates.
Sacopulos: Even if it is off by an order of magnitude, it is still an enormous number, right?
Ranney: It is an enormous number. And I think part of it is because so many of us don’t think about the fact that gun suicide counts, gun domestic violence counts, and having a shooting next to your school counts.
Most of those are not these horrific mass school shootings that strike terror in the hearts of parents. Most of these are everyday events that barely get reported in the news, but that our friends and our families live with the consequences of forever.
There are studies showing that school kids do worse on tests after a shooting in their neighborhood, even if they don’t know the person who was shot. Just knowing that there was a shooting in their neighborhood, they do worse. Kids in Philadelphia are more likely to come to the emergency department with an acute mental illness complaint if they live within a quarter mile of where a shooting took place.
There are all these studies talking about this real health ripple effect of gun violence and if we can focus on decreasing that, it gives us some paths forward that may not be possible when we turn it into this us versus them, gun owners versus non-gun owners. At the end of the day, nobody, whether you are a gun owner or a non-gun owner, wants themselves or a family member to be exposed to this kind of harm.
Sacopulos: Absolutely. And those were really interesting studies and statistics. It seems to me that part of your position is translating that into concrete steps that can be taken to bridge the gap between research and science and actual public policy. On a systems level or an individual level, can you give me some concrete plans? I am struggling. I want something to hold onto here.
Ranney: I know. We all want hope right now. And I think, honestly, if there is nothing else that people take out of this podcast, it would be that there is hope and that becoming numb is not actually the answer. So here are some concrete things that we can do as individuals.
You mentioned policy, and policy absolutely matters, as there are a lot of great policies out there. Things like red flag laws and safe storage laws make a huge difference. But there’s a level below policy that matters just as much.
There are lots of studies showing that safe storage laws correlate with decreased numbers of shootings of kids, either unintentional, suicide, or school shootings. Well, there is a really simple thing that people can and should do, whether or not there’s a law in their state, which is to make sure if they have a gun in their home, it is locked up and inaccessible to those who are not trained users.
If you have family members who are firearm owners, have the same discussion: make sure that the firearm is locked in a safe or with a trigger lock or a cable lock. It is not enough to put it up on a shelf or underneath the seat of your car or in your nightstand, but to make sure it truly is stored safely. That is the first thing that can be done.
A second big thing that we can all do is to be aware of risk factors. Again, talking about this tragedy in Georgia, there were plenty of red flags and risk factors, including mental health. Every clinician who takes care of a patient who mentions suicidal thoughts should ask that patient if they own or have access to a gun. So, know the risk factors and counsel them on safe storage or getting the gun out of the house.
Same thing for domestic violence. Same thing for dementia. We talk to folks with dementia about not driving. Do we ask them whether there is a gun in the home and make sure that it is stored safely?
So, knowing the risk factors for gun violence and being able to counsel folks on getting rid of a gun temporarily or making sure it is stored safely is another step. A third step takes us even further out of the clinical realm: being involved in community mentorship.
One of the best protections for the community is having a caring adult or a parental figure. Programs like Big Brothers, Big Sisters, Boys and Girls Clubs, and 4-H have all been shown to be protective. So, volunteering in our communities to mentor or be involved can make a big difference.
The last thing, if we’re going really big picture, is talking about the environment in which we live. Streetlights, gardens in vacant lots — those all make a difference in the rate of gun violence as well. There are things that you can do if you live in an urban area around beautification that improves safety and well-being in a general way but also has a real impact on the likelihood of gun violence in your community.
Yes, all of those steps have data behind them. They are all evidence-based. And you will note that most of them didn’t actually have to do with passing laws.
Sacopulos: Very nice. That was a hopeful answer. Thank you. It makes me feel better already.
Ranney: Now we have just got to do it.
Sacopulos: Amen to that. It seems to me that historically, public health has been siloed in relation to healthcare. You are obviously a leader in both fields. Do you see big challenges here in terms of integration?
Ranney: That is a great question. I think it is one of the fundamental challenges facing our country. We are seeing dramatic decreases in life expectancy, even after the worst of the COVID pandemic, largely because of a lack of attention to the underpinning of health on a societal basis. Those of us in healthcare are being asked to pick up the pieces of a non-functional health infrastructure.
If you go back more than 100 years, public health and healthcare were much more structurally integrated. And I think going forward, it is incumbent on both sides to work more closely together.
I am fortunate that the School of Public Health at Yale and I are part of a new coalition called the Common Health Coalition that was founded by Dave Chokshi, who is the former commissioner of health in New York City. It brings together a lot of big healthcare organizations, including the American Hospital Association, AHIP, and Trust for America’s Health, as well as some large public health organizations, including the American Public Health Association, that are trying to do exactly this, to think about how we bring the two sides, the individual and the population level, together to address these underlying barriers that are making people sick or keeping them from getting healthy.
I think it behooves us to spend more time and attention on that, to share data, to share resources, and to advocate together for investments in the community that can make the folks that we take care of healthier. If we don’t, I think we are going to keep seeing worse life expectancy, higher healthcare expenses, and more burnout in the healthcare and public health workforce.
Sacopulos: As you know, this is the podcast of the American Association for Physician Leadership, so we have a number of physician leaders listening to us. What tips do you have for physician leaders who are interested in joining you and helping in this cause?
Ranney: Well, I always advocate for getting trained in public health. Certainly, whether through a short course or a formal master’s in public health. Really, it is more than population health and thinking about insurance schemes or ACOs. There are some fundamental but not difficult techniques that we use to look at patterns and analyze them and use them to improve population or community-wide health.
I think partnerships with your local health department are always terrific. Most of us nonprofit hospitals do our community health needs assessment, which can be done in partnership with your local health department and community-based organizations.
And then I would say check out the Common Health Coalition.
For those interested in working on gun violence, most of our specialty societies, at this point, have some great work going on. ABIM, ACS, American College of Emergency Physicians, and AAP all have strong work and resources, so I would encourage folks to look into those.
And lastly, for those physician leaders who are in the C-suite, we have a CEO’s Council working on gun violence that was put together through Northwell Health. I am privileged to be part of that group as well. And they are looking at what C-suite leaders can do to reduce the risk of gun violence in their community.
There are a lot of options out there, and I look forward to seeing more physician leaders get involved.
Sacopulos: Great. Your trajectory as a woman leader in healthcare, the public eye, and academic leadership is, I would have to say, rather unusual. For somebody who is out there thinking, “Can I do these types of things?” how do you pull it off? And what are the challenges and opportunities that you have encountered over your career?
Ranney: To my knowledge, I am the first emergency physician to be a dean of a school of public health, so it is a bit unusual. I am quite proud to be in this role and to represent my fellow emergency physicians, but also, again, to work on behalf of all of us.
I think there are a couple of things. I said this much earlier in the interview, but it really is about following one’s north star, what brought us into this field, into this profession, and looking for the space where you can have the greatest impact. I think that that has been my driving decision-maker throughout my career and has led me to this point.
I do think that research and evidence-creation matter deeply. That is true whether you are working on quality improvement, whether you are writing NIH grants, or whether you are working in partnership with a community-based organization, an insurance company, or a payer. So, thinking about how you can grow your skill set in evidence generation, data collection, and analysis is worthwhile.
The third part, and my guess is that everyone listening to this podcast would agree with this, is to grow a great team. You don’t do anything alone, ever. And gosh, during this podcast, I have talked a lot about my own work, but really, it has all been collective. It has been work that I have done in partnership with other physician leaders, other public health leaders, government officials, and community leaders.
And so, the best tip or guidance that I can give is to find that team and nurture it and nurture the folks within it because that is ultimately what creates success.
Sacopulos: Our time together is coming to an end, but I’m interested to know if you can tell a difference between the students who are attending the School of Public Health now and when you attended it. Do we have a good pipeline of creative people coming along?
Ranney: Well, at the Yale School of Public Health, we have seen an increasing number of applicants and an increasing selectivity in our admissions over the past few years. Certainly, there was a big bump in interest during the midst of COVID, but there remain a lot of bright young minds and middle-aged and older minds that are interested in going deeper into this field.
We have folks at the Yale School of Public Health who come not only from all over the world, but also from a wide variety of professional backgrounds. We have pharmacists, EMTs, lawyers, journalists, as well as physicians and nurses who are pursuing a degree with us and who are so driven to help create the foundational infrastructure for their communities to thrive physically, emotionally, socially, and economically.
So, I am quite enthused about the future. But again, it takes all of us to get there. I look forward to more people who listen to this podcast joining us in that quest to improve the public’s health.
Sacopulos: Well, what a nice way to end. Thank you very much for being on SoundPractice. Thank you for your work because really your success is enjoyed by all of us, and it is all our success. So continued best wishes. My guest has been Dr. Megan Ranney, dean of the Yale School of Public Health. Dr. Ranney, thank you so much.
Ranney: Thank you.
Sacopulos: My thanks to Megan Ranney for her time and insights. Dr. Ranney’s thoughtful approach to the social and health problems of gun violence in this country makes her a true physician leader. My thanks also to the American Association for Physician Leadership for making this podcast possible. Please join me next time on SoundPractice. We release a new episode every other Wednesday.