Jordan Heath-Rawlings: I’d like you to try something for a minute, whether you live in Ontario or anywhere in Canada, think of the news reports that you’ve heard mostly from Toronto that involve gun violence. Make a note of what immediately comes to mind. When you hear one of them. Now ask yourself, how confident are you that the image that just popped into your head represents the majority of gun violence in the province. It doesn’t.
Female reporter: In Toronto this week, a family was torn apart when they lost yet another member to bullets
Male reporter: Surveillance footage shows a silver SUV circling a building. Then it pulls up beside a car filled with people. A single shot is fired.
Second female reporter: Blood remains outside this 24 hour restaurant on Eglinton West near Oakwood after a shooting overnight that police described as showing a blatant disregard for human life.
Second male reporter: Third shooting in three straight nights. In all the cases, the attacks were in heavily populated areas of the downtown core of the city. And there are no suspects in any of them.
Jordan Heath-Rawlings: A lot of factors go into the way the media in Ontario and everywhere else covers gun violence. Proximity to a large audience plays a role, hence the stories out of Toronto, but so does the need for headlines anywhere. And so do race and relationships with police. And a gang affiliated shooting in a dense neighbourhood checks all of those boxes. So you hear about it, but there is a gun violence crisis in Ontario that has nothing to do with the one you probably thought we were discussing today. And the reason that you didn’t realize it was happening is because it doesn’t check any of those boxes I just mentioned. And not only does it not check them, it involves the one thing that journalists who are my age were taught in journalism school, never to report on. So is it any wonder we didn’t see these numbers until they were right in front of us?
I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Natasha Saunders is a paediatrician at the hospital for sick children in Toronto. She is also the co-author of a new study that looks at what gun violence in Ontario really is. Hello, Dr. Saunders.
Dr. Natasha Saunders: Hi, how are you?
Jordan Heath-Rawlings: I’m doing really well. Thank you for taking the time to join us. I want to start by asking you before we get into to the results of the study and what you guys looked at and what potential solutions might be. If I were going to ask,, you know, just an average group of Ontarians what they would expect a study like this, that looked at gun injuries and deaths and the province to find, what do you, what do you think that they would come back with?
Dr. Natasha Saunders: So I think it would depend on where you asked that question. I think if you lived in an urban centre, in Ontario that the response might be a lot about gun violence or, thinking that, firearms are a major contributor to gun violence and deaths in Ontario. If you went into more rural areas, say Northern Ontario, you may get a different response. And there may be increased recognition there that suicide and self-harm are a contributor to, to gun violence. So I started to come to get in. So I think it depends on who you ask and where you ask the question.
Jordan Heath-Rawlings: Fair enough. What about when you started the study? What were the results you guys were thinking you might find as it began?
Dr. Natasha Saunders: Well, based on some of the previous work we had done, we knew that there was going to be a large proportion of individuals in the province who were injured unintentionally. We also knew that our, we expected rather that urban areas would be predominantly affected by gun violence. I don’t know that we knew the extent to which, firearm deaths occurred by, by suicide or self-harm. And so I think that was a bit of an unknown. And when we sort of balance out the overall number of injuries and not, not just compare the deaths. I think that was something that we were, we weren’t really expecting or really knew because nowhere, you know, Ontario, do we record the number of firearm injuries. We only often record fatalities, so that was something that we weren’t really sure of before getting into all this.
Jordan Heath-Rawlings: So tell me then, what you did, especially if we don’t usually record gun injuries and what the study eventually found.
Dr. Natasha Saunders: Yeah, so we use a number of linked health and administrative data sets that are linked at ICS, which is formerly the Institute for clinical evaluative sciences.
And what this does is we have records of health information. So emergency room visits, hospitalizations and deaths in the province linked to some socio-demographic characteristics. So linked to anybody who has OHIP registration or provincial health registry data. And that’s how we determined individual level, you know, age or their sex or the neighbourhood with which they, that, that they live in. So that we could understand the neighbourhood level income quintile. And we also determined if they lived in a rural versus an urban area. And then what we did was we took the whole population of Ontario over this 14 year period. And we look to count the number of deaths,, or firearm injuries, or both through the entire province over this time period. And then, we have data for deaths up until 2016, and that’s why the study ended there. So that’s sort of how the study came about.
Jordan Heath-Rawlings: What was the major cause of injuries and deaths?
Dr. Natasha Saunders: Yeah. So when we look across all firearm injuries that happened in the province, including deaths, there were about 6,500 firearm injuries and deaths over the 14 year period.
In terms of the breakdown we found about a third of those injuries were assault related. So where somebody experienced a firearm injury by being assaulted or from a violent death, another one third were from self-harm, where an individual had a self-inflicted firearm injury, and another third were injuries of, that were unintentional. So where the victim or the individual injured was not the necessarily, the intended victim. What we also found was that the death rate varied. So not surprisingly those who were unintentionally injured had a lower death rates only about seven and 7% of those who were unintentionally injured, died, which is a good thing.
They do represent near misses though. You know, if somebody is shot in the leg instead of the chest, it’s, it’s a pretty close potential for, for death there. What we found with assault is that about a third of individuals who were assaulted died by that assault and of those who were injured by self-harm, 90, almost 92% were killed, so were successful in completing that suicide. So certainly there’s variability in the rate of death by the type of injury, right. But what we did show is that overall that self-harm accounts for a large, the largest proportion. So two thirds of the deaths that we measured of all firearm, deaths. And what we also showed is that it’s really important to measure. Both deaths and overall injuries, because when you only measure firearm fatalities, which is sort of what is often reported in, in statistics, for example, from Statistics, Canada, that is a real under-representation of what’s actually going on.
Jordan Heath-Rawlings: Well and when things are reported by Statistics Canada, that tends to be what gets them into the news and certainly headlines. You know, as you kind of pointed out at the beginning in the major urban areas, tend to focus on the danger of, you know, guns and gangs related shootings.
But what, why aren’t we talking about self harm being such a leading cause of gun deaths? Like, you know, I’ve not seen this report at anywhere?
Dr. Natasha Saunders: Well, well, we should be, if you ask me as somebody who is a healthcare provider, who cares for individuals who ha who are. I’m at risk of, or have mental illness. Certainly, you know, a gun death in the city of Toronto makes headlines almost every day, but we don’t hear about the 45 year old or 50 year old man who is living in Northern Ontario who dies by suicide. And part of that may be related to the stigma that goes along with mental illness, that we don’t talk about it as much. You know, we’re making inroads in certain populations in particular in younger people in terms of reducing that stigma. But I think in rural Ontario, in older individuals, we may have, there’s an opportunity to improve our ability to reduce the stigma that happens so that, so it doesn’t get discussed as much. The other thing is with, you know, this study didn’t look at the, the weapon type. So whether or not it was a hand gun or a rifle, but, you know, there’s a lot of discourse around banning handguns and the legislation surrounding firearms. And that often is related to what goes on in the city. But I think there is a recognition that those living in rural areas often may have a firearm in the home for protection, for example, from wildlife or for hunting. And so it’s not that gang related violence. It’s not people don’t always think of it as at the forefront in terms of, easily preventable death when there was a lot we can do actually to prevent, prevent those deaths.
Jordan Heath-Rawlings: Did the study track whether or not the level of deaths or injuries increased or decreased over time?
Dr. Natasha Saunders: It did. We looked at the rates of injury by intent over time. The rates are pretty stable over time with the exception of in more recent years, we’ve seen a higher number of firearm assaults. And that’s sort of been since around 2014 or 15. Again, we didn’t collect data. You know, beyond 2016, because we don’t have those death data yet, but certainly we are starting to see that trend upward, but overall, in terms of our, our rates of suicide or unintentional injury and generally assault, that is, it’s a pretty flat line. We haven’t seen huge changes over time, and this suggests that, you know, despite this problem existing, we haven’t done enough to prevent it or, or reduce the potential harm.
Jordan Heath-Rawlings: Do you have a way to give me a sense of the scale of the problem ofself-harm with guns in this province? Is it compared, compared to other rates of death or like, you know, how bad is this, how bad is this problem we’re dealing with?
Dr. Natasha Saunders: So suicide is one of the leading causes of death in young people in Canada. So I believe, I mean, it changes a little bit from year to year, but it’s, it’s about the second leading cause of death, at least in young adults. And in terms of firearm injuries, this wasn’t part of this study, but we’ve previously published data to show that around 13% of suicides in Canada are by firearm. And it’s predominantly males that die by firearm injury, whereas women often use other mechanisms. So for example, overdose, but the fatal, you know, quick impulsive, type of injury that occurs with a firearm injury is much more common in males. So about 13% of, of suicides. So it’s, it’s not an insignificant proportion of, of these deaths.
Jordan Heath-Rawlings: Can you explain to me the rural, urban split with self-harm because that seems to be the portion of the study that really grabbed people’s attention.
Dr. Natasha Saunders: Yeah. So this particular study didn’t get at the why of why we’re seeing these differences. Certainly I think there are is a huge, there are huge differences in access to mental health care for those living in urban versus rural areas. Our team has published pretty extensively on this, and what we’ve shown is that those living in Northern Ontario in rural areas have really high rates of suicide and self-harm compared to the provincial average. There are higher rates of hospitalization and emergency room visits for mental illness and really poor access to specialist care. So if you think of somebody with severe depression or severe anxiety, who should probably be seen by a specialist, for example, a psychiatrist or with a mental health care care provider. Access to that in rural areas is very, very poor, and we, our health, our mental health system is not structured in a way that allows equitable delivery of health care, mental health care at this time. So it may be that it’s a, it’s a mental health system access issue. It may be the population where a population where stigma plays a role as well. So it could be a combination of things, but we, but certainly access is, is a contributing factor.
Jordan Heath-Rawlings: And I know it’s traditionally been difficult to get enough doctors in general, let alone specialists to rural communities. Are there ways, ways of creating programs? Are there programs that exist that can maybe offset that lack of access a bit, even if they won’t necessarily bring in, you know, an army of, an army of mental health specialists?
Dr. Natasha Saunders: For sure there are ways. How effectively they can be implemented is a whole other question. Um, so one of the things that has been in the province for quite a while is tele psychiatry. So, um, where I work at the hospital for sick children, for example, child health specialists who are psychiatrists, may provide mental health care to those living in rural areas. The rollout of that has not been as widespread as it could be. So we know that it’s really under utilized. And I think with COVID though, we don’t have the data yet, we know that there has been a huge shift to virtual care, which in theory should break down many of these geographic barriers. So anybody with an internet connection or a phone or a computer should be able to access some of the same services for counselling or for psychiatric care in an outpatient setting, which is, you know, largely a lot of the preventive care with the shift to virtual care. And we’ve seen a huge transformation with COVID. And so it is my hope that this will help to break down some of these barriers as we move on. So that the, the urban rural divide in mental health equity doesn’t continue to exist.
Jordan Heath-Rawlings: How much, and I know I’m asking you to, to answer something that’s not in the study, but I’d love to have your opinion of how much, how much does the stigma impact, rural communities compared to urban ones when you look at who talks and who doesn’t talk about their mental?
Dr. Natasha Saunders: Oh, that’s a really good question. I don’t know. You know, I personally haven’t done a lot of work up in more, more Northern Ontario or rural communities to speak to patients. I think stigma continues to play a role everywhere. And I don’t, I don’t think it’s just rural areas that the stigma exists. I think we see it in many different populations. I don’t think we know.
Jordan Heath-Rawlings: What about ways to end the stigma or at least reduce it? How do you get that message across? And I would say particularly to rural communities, but it could be anywhere. I mean, when I came up through journalism school and, and I think tons of young journalists came up the same way. We were told specifically you never ever report on a suicide because it could potentially encourage more people. And now that we learn more about mental health, I wonder if that’s still effective.
Dr. Natasha Saunders: Yeah. I think having discussions, opening up conversations are really important so that people feel comfortable talking about their mental health. And I think it’s increasingly being recognized. How can we do it? I think there are many ways. I think in, in our school system, I think we can start early on by talking about our mental health and ensuring that there are our resources there.
I think, you know, in, in healthcare, certainly providing an opening and giving families or individuals opportunities to discuss their mental wellbeing and placing it at the forefront of their physical health, placing it ahead of their physical health needs often because you know, we often talk about your blood pressure or your heart disease, or what have you, but we don’t often talk about mental illness and it goes undetected. And if you give patients or families and opportunity to talk about that, then I think it, it opens the door for that discussion so that individuals can get the help they need. So schools, I think also workplaces can also potentially provide safe spaces. So, at our organization, for example, there are many different resources for staff to access mental health support. Especially for example, through the COVID 19 crisis and having workplaces that have environments that are accepting of, or, or friendly for individuals to come and speak to somebody confidentially can really be helpful and get the conversation going so that individuals can get the help that they need.
Jordan Heath-Rawlings: This study basically just came out. So it’s, it’s too early for any concrete action to be taken. But if over the next year, levels of government could address this particularly in, in the province, I guess, since it focuses on Ontario. What concrete things need to happen? What’s a great, a great first step?
Dr. Natasha Saunders: So I guess when it comes to what the government can do, so people often talk about firearm legislation, which is actually a federal. This federal legislation it’s not provincial. And so I think it would have to be discussions with the federal government as opposed to the provincial government. But, you know, with that said, I think currently as a, as a healthcare provider, we often want to ensure that firearms are removed from the home, or the environment of those who are at risk of self harm or who are struggling with mental illness.
And currently there are not easy ways to do that. So if I have a patient who has a mental illness and, and I always now ask if they have access to a firearm in the home, you first, there’s a discussion around the safety of that firearm in the home. And how do you, how do you get that out of the home and counselling them around the risks in individuals who are at risk of self harm. But then beyond that if a family or a patient is not willing to temporarily remove that firearm from the home, then what are the options? And it becomes a little bit more tricky because as a physician, I can’t just, you know, I don’t want to send a police to a house to remove a firearm from the home. So if there were easier ways, in terms of the balance between patient confidentiality and, patient safety to make sure that firearm could be removed from the home, that that is something that we could do moving forward. I think, you know, there’s the government who can legislate things. But at the same time, we also, as healthcare providers need to think about ensuring, we get this message through to everybody who is providing care for those who are at risk for mental illness, so that we can counsel individuals to get firearms out of their home so that they’re not accessing well.
Jordan Heath-Rawlings: Thank you so much for taking the time to walk us through that. And I hope we see some action out of this study.
Dr. Natasha Saunders: I hope so too, thanks so much.
Jordan Heath-Rawlings: Dr. Natasha Saunders. That was The Big Story. For more head to thebigstorypodcast.ca find us on Twitter @thebigstoryFPN. Find us in your podcast player, every single podcast player in the world, I think. If you find one and we’re not in it, tell me, we’ll make sure we’re there.
You can also of course, email us firstname.lastname@example.org. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.
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