E106 John Kortbeek On Gun Control
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:43
This week on the podcast, we talked about a topic that we've heard about all too frequently on the news - gun violence. We were lucky enough to be joined by Dr. John Kortbeek, a trauma and critical care surgeon at the University of Calgary. We asked Dr. Kortbeek about the topic of gun control in general and specifically on gun control policies in Canada, and how general surgeons and general surgery residents can get involved in political advocacy.
John Kortbeek 01:09
I grew up in Edmonton and went to school there, including medical school at the University of Alberta. At that time, when you finished high school, your choices were simple, you went to work, or you went to the University of Alberta. The whole notion of going elsewhere to study in postgraduate studies was a real rarity back then. But I had great training and completed that, and I went on to complete general surgical training at the University of Calgary after an internship in Ohio. I then pursued additional training in critical care and trauma, both at the University of Calgary and in Birmingham, Alabama, which was a great experience. It really opened my eyes, and I learned a lot. And since then, I've been practicing in Calgary, Alberta. For the past three decades in general surgery, trauma and critical care.
Chad Ball 02:04
You have really been a pillar on a foundational person or piece in Canadian trauma care on really every level. And we could talk to you about so much of that for so long. But really what we want to focus on today, and I hope you're still willing, is to talk about gun control and gun violence in particular and how that relates to us as surgeons across the country and maybe comparatively throughout the world. So, I'm curious if you could start off by teaching us a little bit about gun use, gun violence, gun injuries in Canada, and I think in particular for a lot of us, yourself included who have spent, you know, years in the US, maybe framing the differences between countries and culture as well.
John Kortbeek 02:53
Well, that question covered a lot of ground. So maybe I'll start at the beginning and describe why I became interested in injury control and reducing the burden of injury due to firearms. I grew up hunting with my dad and we would go bird hunting in northeastern Alberta, mostly ducks, occasional geese. So, I grew up using a 12-gauge shotgun. And my parents also thought it was important for me to learn what it was like to, you know, live in the rural area. So, they sent me out to a French-Canadian farm for a couple of summers. And at the age of six and seven, I was unleashed on the gophers with the 22s and getting a few cents a tail as a reward for any that we were able to capture and shoot. So, I became familiar with guns at an early age and then didn't do much hunting for a long time. But more recently, as I've had a bit more time, I started hunting with friends and family. I have members of my family that hunt big game and birds and I don't own a gun, but I enjoy going out with them and walking in the woods and I enjoy the fruits of their labor and some fine venison afterwards. Like both of you, I've dedicated most of my career to trying to care for the patients in front of me. And as a trauma surgeon a big part of that was improving care for the injured and we spent a lot of time improving trauma systems in Canada and working with other countries to improve education and trauma. And when we did focus on injury control, particularly in the 80s and 90s, the greatest burden of injury was from motor vehicle crashes. So our injury control efforts were focused on that and rightly so. But over the past decade, I've had a greater awareness of the increased burden of injury from firearms. I think the eye-opening event for me was the Claresholm mass shooting event which occurred in Alberta about 10 years ago. It was a group of kids coming home from college for Christmas. And they were chased down and then shot by a deranged ex-boyfriend with a semi-automatic legally purchased handgun. There were three of them who were killed at the scene. The gunman committed suicide and the one sole survivor arrived at our trauma center. We cared for her for a number of weeks afterwards. And I just thought that was tragic and a complete waste. And then over the last decade, I've noticed a steady increase, or at least I seem to notice a steady increase in gun violence in Calgary with a greater number of admissions primarily from handguns in our trauma centers. The final inciting event was the Danforth shooting when one of our colleagues Dr. Nagiman spoke out about the injury she had seen. And, you know, brought up the issue of gun control and rather than being debated on the merits of her arguments, she was attacked personally with a number of complaints submitted to the college, which were eventually dismissed as vexatious. But she approached a number of trauma surgeons around the country for help. And together, we formed an organization called Canadian doctors for protection for guns, with the goal of approaching the burden of injury due to firearms as a public health measure. So those are the events that led to me to be speaking to you today about this subject. So, the question is, where does Canada stand with respect to gun injuries and firearm injuries? And is it a public health issue in Canada? And if you look at the global burden of disease from firearms, there's an excellent study that was recently published as part of the global burden of disease studies which are personally supported by the Gates Foundation and emanate from the University of Washington. And this one described the numbers which are somewhat horrific, there are approximately a quarter million people a year that die due to gunshot wounds, and about two thirds of them are homicides. 1/3 are suicide, a few are unintentional. The interesting thing is they're certainly not evenly distributed around the world. There's a number of countries that are very high incidence of injuries and deaths due to firearms. And that belt extends from the United States through to Mexico, Guatemala, Venezuela, Colombia, and Brazil. And they together account for about half the global burden of disease. The United States and Brazil, together account for over 30% of the global burden of disease for firearm injuries. And it's quite striking when you travel around the world if you're fortunate enough to visit other countries. You know, I had the good fortune to teach in Laos, for example. We were teaching a trauma resuscitation to residents there who had never seen a gunshot wound. So that was quite striking. And certainly, Canada compares favorably to those countries. But we don't compare quite as well to, like countries meaning high income countries in the OECD group. In the OECD group, Canada has the fifth highest rate of deaths due to firearms. We have a higher rate of suicide due to firearms compared to the global average and a lower rate of homicide. But together our numbers are still near the top amongst that group of countries which are similar to us. When you look at Canadian statistics, the numbers of people killed each year, approximately 600 out of the 4000 suicide deaths are due to firearms. So about 20% of suicides. With respect to homicides, there are about 600, 650 people that are murdered each year in Canada, and about 270 of those patients are killed by firearms. Besides that, we are seeing at least locally an increase in the number of patients that we're admitting with firearm injuries to our trauma centers. So, we recently pulled Alberta trauma registry data and the Alberta trauma registry data showed that the numbers have doubled over the past 10 years from 30 to 60. ISS 12 admissions per year. But we know that ISS is not a good measure for penetrating trauma as these patients could have multiple anatomic organ injuries in one compartment, so they don't score high despite having severe injuries. In Calgary, we're fortunate we capture all patients admitted for firearm injuries in our trauma database. And interestingly, and perhaps shocking at the same time, our numbers went from 9 a year in 2009 to about 50 a year over the last two years suggesting that Alberta is now admitting over 100 trauma patients a year secondary to firearm injuries. And if you extrapolate that, across Canada, Alberta has a higher rate of firearm injuries than the Canadian average. But it still means that there probably between 500 and 1000 patients who've suffered injuries from firearms that require admission to hospital each year in Canada. And beyond that, of course, there's an increase in violent crime, which is primarily associated with handguns, about 7000 incidents last year, from what I can tell, and the trauma and stress that comes with that. So, in Canada, we're not as bad as our neighbors to the south, but we're in a bit of a bad neighborhood.
Ameer Farooq 11:11
Dr. Kortbeek, you've talked about sort of where Canada is in the global kind of scale of things. Can you talk a little bit about what gun control measures are actually present in Canada right now? Because I think that's a significant kind of source of kind of confusion among people and understanding the differences between the US and Canada in terms of gun control?
John Kortbeek 11:35
Sure. Well, I think, first of all, it's important to just back up a bit. And whenever people talk about the burden of disease due to firearms, the debate immediately polarizes into gun control versus no gun control. And we actually don't approach any other public health issues that way. So, you know, the first question is, is it a public health issue, and a public health issue means that there's a significant burden of disease that it could potentially affect anybody or most of the community. The incidents might be rising, there's a significant cost associated with that disease, there may be significant disability associated with the disease, and most importantly, that the disease is potentially preventable. The other thing that's really important when looking at anything through a public health lens is the pragmatic realities of public health, which are that to address an issue, it has to be acceptable to introduce measures in the culture in which you live. It has to make economic sense, and the political will has to be there. And usually, the political will follows the former to mean that the culture or the body politic will accept the measures. And they make economic sense, or they're at least economically viable. And we're seeing that play out in real time, with COVID, where there's the science of preventing disease transmission due to the COVID virus. And then there's the political reality of wrestling with what a public will accept, and what does it cost to implement the measures. And that has played out differently even across Canada, as we all know. So those measures are really important when looking at addressing the burden of disease due to firearms. And typically, when we discuss public health ventures, we talk about the ease of public health, which are effective care. And again, all three of us have spent most of our lives trying to improve effective care. And in Canada, we're fortunate to have really good trauma systems with ready access to prehospital care, rapid transport to trauma centers, and appropriate triage and good care in hospitals and good rehab. So there have been huge improvements in that. So that leaves the other measures that could be used to approach the burden of injury due to firearms, which include engineering, smart guns, enforcement, which means legislation and enforcing that legislation. There's no sense having a law if you don't enforce it. It means creating an environment where you reduce the risk of that injury and that's where gun control comes in, in terms of the gun, and mostly handguns and military style assault weapons in the context of reducing the burden of disease and the specific topic of gun control. The history of that environmental part of the public health issue of firearms in Canada is iterative, meaning that we've either introduced a number of measures slowly over time. But primarily in Canada, they involve licensure registration, and background checks. So, in Canada, in order to procure a firearm, you're required to submit an application to obtain a palace license. You are submitted to a background check which looks for evidence of criminal record or mental illness. And it also requires that you undergo mandatory education before you're granted a license. And then the ongoing requirements in your ability to transport the weapons depend on whether it's an unrestricted weapon, meaning that typical shotguns and hunting rifles that most Canadian gun owners own and the more restricted types of weapons, which include handguns and military styles, semiautomatic assault weapons, which are the ones that are of most interest to those of us involved in public health and trying to reduce the burden of disease from firearms. So, all that has evolved over time in Canada, the most recent legislation included Senate bills, C 71, and C 21. And they brought in additional requirements for background checks, extending the timeframe of the check beyond the five years to any time in the past for a history of criminal behavior, or mental illness, and some more stringent requirements on transportation of restricted weapons. And then the most recent bill is bringing in a number of additional measures which remain in evolution. But those include red flag laws, which allow people who are identified as potentially being at risk of suicide or posing a risk to others for homicide or harm, of having their guns temporarily removed. You can think of it a little bit like taking the keys away from a drunk driver is one analogy that was used to describe red flag clause. It also potentially will ban military style assault weapons with large capacity magazines, those would be the probably the two most important measures in addition to the ones I've already mentioned. So, licensure and regulation of firearms in Canada is nothing new. It's been around for 100 years, but it has waxed and waned over time. The most controversial policy was probably the introduction of the long gun registry, which was introduced and then withdrawn. But that's the history of legislation in Canada.
Chad Ball 17:58
You know, your description of the nuances of that are all so helpful. And I think interesting, and the way that, you know, not surprisingly, I think, you know, in agreement from a lot of us, that you framed it in terms of a public health issue and potentially crisis. That does make a lot of sense. But, you know, if we move sideways for a little bit, I wanted to ask you about the emotion of it, and what your impression was regarding that, because, you know, in the US, it is obviously such a hot button issue that doesn't seem like it can move forward because of that political system. And certainly, you know, the importance of the Second Amendment and having a regulated militia, to sort of maintain the security of a free state, so to speak, goes back well over a couple 100 years. I get all that, but we don't really have that same history in Canada, or certainly a lot more soft spoken about it. But my sense as I'm sure yours is and talking to people one on one quietly, there's still a lot of passionate concerns about any movement forward with regard to gun restriction and really the importance of a lot of these firearms. I'm curious, what your sense of that emotional interaction with the data you presented is?
John Kortbeek 19:18
Yeah, I think it's always important to respect opinion. But as physicians, we have a professional obligation, not only to provide the best care we can for patients that are immediately in front of us, but we also are expected to advocate to improve the health of the populations we serve. That's an expectation that's written into the accreditation of our medical schools, whenever we call it evaluations of the students and residents that rotate on our services, often one of the checkboxes that we complete is, you know, are they aware of the determinants of disease and do they have a broader outlook on how to reduce the burden of illness from the diseases on that rotation. So, we do have a professional obligation that we are held to. And again, it's okay to have an opinion. But it's important to frame that opinion as physicians based on evidence. Again, people have very strong opinions in the current pandemic, on vaccines and public health measures. Yet, universally, our professional organizations have stuck to the science and made recommendations based on what the best public health measures are, in order to mitigate the effects of the pandemic. So, gun violence, and the burden of disease due to firearms should be no different. The United States, as you mentioned, is different. And Canada, our only neighbors are the United States. So, we are affected by what goes on in America to a great extent. And the US has a different history and culture than we do. We share a lot of culture with the United States, but we also have a different legacy. And, you know, peace order, and good government is kind of the Canadian phrase that describes us. And I think it's, you know, it rings true if you've traveled across this country and experienced it. In the United States, the Second Amendment, which as you pointed out, was brought into allow a well-armed militia to protect the state against autocracy was certainly the intent. I'll leave listeners to judge how well that is working in recent times. But the Second Amendment does not prevent states or the federal government from prohibiting types of weapons. So even in the United States, there's quite a bit of variation between states on what is and what is not accepted on the degree of background checks and licensure and training that is required to purchase a firearm, which allows for a big, natural experiment, because the United States is so large. And the United States also has a couple of other pieces of legislation that indirectly affect us. One is the Dickey Amendment, which prohibited the CDC from investing public funds in gun control research, which dramatically reduced research into the burden of disease and effective measures in mitigating gun violence in the United States. And then they also brought in tort legislation which prohibited litigation against manufacturers and sellers of weapons, in any other business, including cars, if you create a product, which harms others, ultimately, you're held accountable and liable for that. But firearms remain the exception. We don't have a large, you know, domestic manufacturer in supply of, you know, handguns, military style assault weapons. So, the tort issue in Canada affects us because if you want to sue, you have to sue across the border. The research piece, you know, the Canadian research enterprise, it's smaller than the American one. And there's hasn't been interest until recently in researching measures that would mitigate the burden of injury from firearms. But one of the reasons we found the Canadian doctors for protection from guns was to create a professional organization that would invest in research to address and provide evidence for effective public health measures in reducing the burden of disease. So, there are important differences between Canada in the United States, but we are influenced by our neighbors to the south, there's no doubt about it.
Ameer Farooq 24:07
Just to kind of double down on what Dr. Ball is saying and echo what you're saying about kind of the emotion that dogs this whole debate. I mean, even in your recall that, you know, as part of your role in the organization that you're talking about, you know, there was a rally and some demonstrations and some more, you know, political involvement, that you were part of organizing and administrating. And you'd kind of passed this message along to the residents in Calgary, again behind closed doors, just an email chain. There was significant (without naming individuals), but there was some significant consternation among the resident body with some residents really getting upset that you know, why are we even part of this whole you know, gun control thing you know, we use our guns peacefully. And we have great laws in Canada. So why are we trying to take away guns from everyone? And there was quite a bit of, you know, debate and an argument even within the residents in Calgary. So, you know, my question to you is, what do you think the actual implications are of bringing forth some of the legislation and amendments that the group is proposing, specifically, I'm thinking around assault rifles and educate me about any other particular actions that the group is taking? But what do you think the real impact is going to be of making these kinds of changes and trying to advocate for this?
John Kortbeek 25:40
Right. So I think, you know, I was recently on a CAGS membership committee meeting, and we were discussing topics for future Canadian surgical forums and polling the members and one of the suggestions was we should poll the members regarding what their thoughts are on gun control: are they for it or against it? And my comment was, well, before you do that, you need to educate people so that they understand what the evidence is, and what is being actually proposed. Because the strong opinions often are based on opinion and not fact, without even understanding what is being proposed, what is being discussed, and what is the evidence behind it. And I think that that probably was true of the email discourse with your residents. If you asked any of those residents, you know, what measures are being proposed? What is the evidence for and against those measures? Which firearms are being discussed? And what is the burden of disease in Canada? I doubt if any of them would have been able to answer those questions. And yet they were voicing strong opinions for and against the issue. So, the first step, and again, this is one of the eases of public health is to educate people so that they understand what the evidence is. So, one of the questions is, you know, what is the burden of disease? And what are the factors that affect that burden of disease. So, I've already described what the numbers are in Canada. There are three main factors that are associated with the burden of disease with respect to firearms and injuries. And those have been in a country that is a either a producer or a major transport conduit for illicit drugs. Unfortunately, Canada's neither of those things. Guatemala is, which is why it's in trouble. The second is, the worse your Social Development Index, the higher your probability of interpersonal violence and gun violence is, and the highest social development index in the world is, typically Norway, and STIs are based on literacy, access to education, you know, birth rates, that approach replacement, access to health care, all the things that we associate with good quality of life, and that we enjoy in Canada. Canada scores quite high in STIs, with one exception. There's a lot of heterogeneity amongst our indigenous population in Canada, with some groups doing well and others doing poorly, but as a group, they tend to have a poor social development index than the rest of Canada and as a result are overrepresented in the burden of disease due to firearms. So, Canada has an opportunity to provide greater access to economic opportunity, education, etc., to our indigenous peoples. And I think the country is slowly waking up to that. And the indigenous peoples themselves are becoming more active in advocating for themselves as well. So hopefully, we'll see some improvements there because they are overrepresented in firearm injuries and deaths in Canada. And then the third factor, which is clearly associated with the burden of disease around the world, is the number of firearms. And the firearms that are associated primarily with interpersonal violence, and to some degree suicide, and certainly with admissions to hospitals are handguns. And the firearms that are associated with multiple mass shooting events are military style weapons, you know, semi-automatic weapons with large capacity magazines. So, with respect to gun control that restricts access to those weapons, the question is, does it make a difference? And the best example of whether it makes a difference or not are number one, is there an association between the prevalence or access to those firearms and the burden of disease? And the simple answer is yes. If you go down the list of OECD countries, the greater the number of firearms, the higher the incidence of firearm injuries in Canada is actually one of the top five countries in terms of its index with respect to firearm ownership. US is clearly at the top. But you know, we have a greater number of firearms than most other high-income countries. What we don't know is what are those firearms? At least I don't know what they are. Somebody may have that information, certainly, the federal government through its registration, you would think would. But I wasn't able to find it. And the distribution of firearms and shotguns, which are seldom associated with interpersonal violence. And not clearly associated with suicide, versus handguns and military style assault weapons, which are associated with those things. I don't have that breakdown for Canada. So, I don't know what it is. But I do know that we have a high number of firearms compared to other countries, and we have a higher as expected burden of disease. And then the second question is, well, what happens when you change the environment. So, the best examples of that come from the UK, which has a long history of gun control. In fact, the British were worried after World War One, they already began restricting military style weapons going back nearly a century. But they had access to handguns, including semi-automatic handguns, as well as hunting rifles through most of the 20th century. And then they had a terrible event where they had a mass shooting in the northern UK, where I believe 16 children were injured, and another 16 were killed along with the teacher. And there was such a public outcry and so much horror expressed as a result of that event that they subsequently banned handguns. And they have seen a significant progressive decrease in the number of firearm injuries. Their rate is about 1/10 of the rate in Canada right now. So, they clearly have shown a benefit from restricting access to that type of weapon. The other example is Australia, which also had a mass shooting event where I think over 50 people were shot. So that was in Port Arthur, again in the mid-90s, and over 30 people were killed. And their reaction again, was as intense as was in the UK. They banned military style assault weapons. And they didn't ban handguns. But what they did was they said, well, you can't buy a handgun for self-defense. If you are an active member of a shooting club and you participate regularly in target practice, and document that, then you can undergo a six-month probationary period where you use a weapon that is secured on site storage that belongs to the club. And then after that, you can, you know, purchase your own weapon. They also had a buyback program for the weapons that didn't meet the bill with respect to their legislation. So, they decrease the number of firearms in the country. I think they purchased almost three quarters of a million weapons during their buyback program. And again, they saw a tremendous fall in the burden of injury due to firearms. And the other thing that is interesting in Australia is that they like Canada, Canada has had 19 mass multiple shooting events over the past three decades, but we've had six of those in the last five years, including the Nova Scotia massacre last summer. And Australia was having similar numbers, they were having about three every four years. After they introduced legislation, they outlawed military style assault weapons, and they had a huge buyback program and they severely restricted access to handguns. They've had zero mass shooting events in 20 years. So, the evidence is quite striking. There's clearly an association between access to these firearms handguns and military style assault weapons and the burden of injury and there clearly is an associated decrease in the burden of disease in countries that have further restricted access to these weapons. In Canada, most gun owners, ranchers, hunters, farmers, own hunting rifles and shotguns. But there are people who own handguns and military style assault weapons. I went on a website this weekend. And you know, just checked to see what you can still buy. And you can go out and purchase, you know, a military style semi-automatic weapon with a large caliber magazine, which is defined as important 10 rounds that you could purchase magazines with 20, 30 or more clips in a single case, and go out and be on your merry way. So those weapons are still available in Canada. And as long as they're available, we will continue to see endemic violence from handguns, and we will continue to see multiple mass shooting events irrespective of the fact that most people who own those weapons are illegal gun owners who abide by the law. There's clearly an association between restricting access to those weapons and the burden of injury because it only takes one person who's deranged, troubled, or a lunatic to commit mass murder. And the prevalence of handguns is associated with endemic interpersonal violence, femicide, etc. Finally, one thing that people should be aware of, and this may not have been reflected in the email chain, because people with strong views tend to be overrepresented. And that was nicely described in your recent podcast on social media. But in Canada, polling has shown that 80% of Canadians supported the recent changes in the federal bills. 80% of Canadians support abandoned military style assault weapons, with large capacity magazines. And over 60% of Canadian support restrictions or bans on handguns. And those things would do nothing to interfere with the ability of farmers, ranchers, or hunters to enjoy their sport or protect their property or their livestock. So, the political arena is such that in Canada, it would be supported to pass the tip of legislation, even though there would be a vocal minority against it. There's evidence to support that legislation. We haven't gotten into the economics, but there's a clear economic benefit, both from the direct hospital costs and the indirect society, your cost from loss of GDP from all of the people who've been shot and injured or killed that could be considered. And the final thing to remember is that the people who are shot, injured or killed, have rights too. They didn't ask to be shot, they didn't ask to be killed, and they didn't ask to be disabled. And that's a pretty stiff price to pay for ready access to handguns and military style assault weapons. So gun control measures that change the environment by restricting access to those weapons do make a difference. Physicians need to be aware of that when they debate the subject. It's okay to have an opinion. But again, the opinion should be formed on evidence.
Chad Ball 38:08
That's beautifully summarized. I mean, clearly every country is different, and the culture of every country is unique. But I think putting it in that international perspective is helpful, and it is relevant, and it is informative. I'm curious if you had any specific comments on you know, most recently, the New Zealand experience and their ability to ban handguns, especially banned assault rifles that quickly, it seemed like from the outside as well as talking to folks that you and I both know, within New Zealand on the surgery side that that did happen very rapidly based on that event and was widely supported. And I don't know. I mean, based on what you've just told us, maybe it is and would be the same thing here. But I'm curious how you put that into the lexicon of what you've talked about?
John Kortbeek 38:59
Well, I spoke to a senior politician recently. And one of the questions they asked was, if the polling data are as favorable as they are, and they are because they've been repeated by multiple independent agencies, why does the political leadership not act on it? And the answer I received was that while 80% may support these measures, but the 20% that are vocally opposed will vote based on those measures and the 80% that support restricting access to those weapons usually do not put it at the top of their priority list for who they choose to vote for. And there also is a difference between rural and urban writings in terms of what people will support, what the cultural expectations are, which also flavors the political discourse. What happens and this happened with the Dunblane massacre in the United Kingdom. It happened with the Port Arthur shootings in Australia, and it happened in New Zealand, and it also happened in Canada with the Nova Scotia mass shooting, is that those events are so horrific that they galvanize public opinion. Now, people who advocate against any restrictions on the sale of firearms, including handguns, military style assault weapons, will dismiss multiple mass shooting events, saying that they are, you know, rare, but unfortunate. They're like shark attacks. But another view of multiple shooting events is that they are similar to airline disasters. They're so horrific, that everything possible should be done to prevent them. And at the time they happen, they galvanize public opinion to allow you know, the politicians to move forward with legislation that addresses these issues. So New Zealand is a small country. It has a population about the same size as Alberta and BC. So, it will take a long time to understand the effect of those measures. But based on the evidence we have from the UK and Australia; Danny military style assault weapons should reduce the number of multiple shooting events. Even in the United States, the United States for a decade banned large capacity magazines, and then that was repealed, I think in 2004, but don't quote me on the date. And the country as a whole has seen an increase in multiple mass shootings since the repeal of that ban. But there are more than half a dozen states that continue to have bans on large capacity magazines. And now you can drive from state to state so there's nothing to prevent somebody from purchasing those weapons in one state and taking them to another. And yet, despite that, the states that have large capacity magazine bans have carried forward that reduction in mass shooting events and have a lower rate than the states that do not have those bans in effect. And they also have fewer deaths per shooting. And it makes sense because if you're going to commit mass murder with a weapon that is not capable of a semi-automatic fire and doesn't have an orange capacity magazine, it will be more difficult to kill more people. So, they have seen beneficial effects from those limited bans. New Zealand undoubtedly will see the same thing. There was broad public support because opinions galvanized by the horror of what happened there. And to some extent, we've seen that happen in Canada. Canada's a much bigger country. You know, we have large geographic separation between provinces. Sometimes I think of Canada as the land of the 10 kingdoms and three territories with each one behaving a little bit like an independent nation state. So, you know, we tend not to be as horrified by events that occur far away as the ones that occur in our backyard. But you know, those events do make a difference in terms of political will.
Ameer Farooq 43:11
Dr. Kortbeek, one of the things that we've explored a lot on the podcast is the role of surgeons and physicians in the political arena. And more broadly, in sort of speaking out around social issues. Certainly, we saw that after the Black Lives Matter movement over the summer, where, you know, a number of physicians and healthcare systems frankly had their own kind of internal reckonings and really had to make some big statements around that whole issue around diversity and racial equity. And certainly, gun violence is also an important public health issue. And yet, you know, there is always this kind of struggle and this tension and this conflict about whether physicians should be kind of inserting themselves into a somewhat charged situation or issue, especially one that may have political kind of implications or associations with it. I'm curious sort of your thoughts, having engaged in this work on our broader role societally, in doing political or societal type of work and speaking out on that? And particularly, if you feel like, and we've sort of talked about this already, but if you feel that gun control is one of those issues or if you know, to you that the link there is much clearer, given all the public health data around it.
John Kortbeek 44:46
Well, I think that, you know, again, the first step is to inform yourself so that you understand what the issues are and decide if it matters to you. One of my definitions of a great country is one where I can go for a walk and not have to, you know, walk in fear. And I've traveled quite a bit around the world through my professional career. I've been very fortunate. And there are plenty of places in the world where you cannot go for a walk, it's not safe to do so. I live in a community where it is safe to go for a walk. And I'd like to keep it that way. So apart from the tragic circumstances involving many of the patients we care for, and a desire to see fewer people, like, you know, those kids that I described who got shot going home for their Christmas vacation, I just would like to have a safe community for myself, my family, my friends. So that's why I think this issue is important. And the issue isn't gun control, the issue is reducing the burden of injury due to firearms. And it's not all firearms that are responsible for that burden of injury. It's specific ones that I've described, which are handguns and semi-automatic military style assault weapons. Most physicians are not, you know, comfortable embracing the media, and most people like to avoid conflict. It takes training and experience to be able to advocate at that level. But the good news is that most physicians don't have to do that. But the first step most people should take is to get informed so that they understand the issues, and that they can speak from evidence so that they're not engaging in social media, forensic feeding chains that are based on opinion and not evidence. The second thing they can do is participate through their professional societies in formulating statements and guidelines that support evidence based public health measures that will address the disease or injury that they feel passionate about. And we all do that. We all, you know, belong to societies that recommend screening for colorectal cancer. We historically, in injury control, advocated for measures that included better enforcement of speed laws, mandatory seat belts. Back in the 60s, it was controversial to suggest that you shouldn't smoke. But over time, most professional organizations adopted evidence-based recommendations that suggested that smoking was bad for your health in many ways. And you know, reducing the burden of injury from firearms is no different. It's reviewing the evidence and through your professional organizations and societies, making recommendations based on that evidence that can and will reduce the burden of disease. And that ultimately may be acceptable on the pragmatic parameters I've described, which are culturally acceptable, economically feasible. And finally, the political will to achieve them. And the politicians are more likely and able to drive through legislation to change public health guidelines and enact measures that affect public health, if they know that the professional organizations support them. So, for example, with the recent bills that I described, the Canadian Doctors for Protection from Guns was one of many professional organizations that had an opportunity to present to the federal government and provide a summary of the evidence that supported the legislation. And those are things that physicians are good at. And they don't require getting up in front of a mic and talking in sound bites to potentially hostile questions. And being in a pro con debate with somebody who's taking a polar opposite view that may not be evidence based. A few will have to do that. But not everybody has to do that. In fact, the majority do not.
Ameer Farooq 49:02
Dr. Kortbeek, if people want to get involved in either the advocacy side of reducing the burden from firearm injuries or in the research side, what advice do you have for people and where can they turn to get involved?
John Kortbeek 49:17
We just had a grand rounds in the Department of Critical Care in Calgary and I invite colleagues from Edmonton to join. So, the first step is, again, becoming informed through education. And then once you're informed, sharing that with your colleagues, most of whom are not aware of any of this evidence that I've presented today, so that we can become better educated professionals and speak from you know, evidence and knowledge. And the next step is to get involved through your professional organizations. Or join an organization that will advocate on your behalf. And Canadian Doctors for Protection from Guns is an example of that. As I said on CAGS, I've suggested that we have rounds at some point in the future on this issue to educate our members. And then the final step, I think, is to, if you feel passionate about a subject and you've informed yourself and you're aware of the evidence, and you can speak from a position of strength, is to help those organizations start framing statements or policies that reflect the evidence in terms of tapping this as a public health issue. And so, for example, there are probably about 20 professional organizations now that have statements on public health measures to reduce the burden of disease from firearms. The Canadian Medical Association is about to come out with a statement. First one on addressing this as a public health issue. And those are necessary, iterative of baby steps that are required to tackle this. Just as the framework to identify the health effects of smoking have come up with public health recommendations to try and reduce that. That took many years, and this will be no different.
Ameer Farooq 51:25
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