 Good afternoon. Thank you all for coming. Dr. Selwyn Rogers, who's in the back, and I are delighted to welcome you to this, our sixth lecture in the 2017-2018 series on ethical issues in violence, trauma, and trauma surgery. I'm delighted to introduce our speaker today, Dr. Marie Crandall. Dr. Crandall is professor of surgery at the University of Florida, Jacksonville, the director of research for the Department of Surgery, and associate program director for the general surgery residency. Dr. Crandall obtained her bachelor's in neurobiology from UC Berkeley and attended medical school at the UCLA Charles Drew program in Los Angeles. Dr. Crandall did her general surgery residency here in Chicago at Rush and at Cook County Hospital. In 2003, Dr. Crandall completed a trauma and surgical critical care fellowship at Harborview Medical Center in Seattle, where she also took a master's degree in public health from the University of Washington. Dr. Crandall spent 12 years at Northwestern University working in the division of trauma and surgical critical care and held faculty appointments at Northwestern, both in surgery and preventive medicine. Currently, Dr. Crandall is a member of the division of acute care surgery at the University of Florida, Jacksonville. Dr. Crandall performs emergency general and trauma surgery, works in the surgical ICU, and is an active health services researcher. She's published extensively in the areas of injury risk factors and outcomes, health disparities, geographic information systems in trauma research, gun violence, and violence prevention. Dr. Crandall is chair of the Publications Committee of the Association of Women Surgeons and is the co-chair of the American Public Health Association's Gun Violence Prevention Workgroup. Dr. Crandall's talk today, as you see up on the screen, is using geographic information systems and trauma research. It's a pleasure to welcome Marie Crandall back to the University of Chicago. It is such a pleasure to be here at the University of Chicago. I had never actually attended the University of Chicago. Dr. Sigler asked me when was the last time I was here, and I recalled that it was when I came to hear an Angela Davis lecture at U of C about six or seven years ago. But then I realized that I was actually invited to some social justice meetings that occurred around the time of some of this research that I'm going to talk about. So I promise you that the second most boring thing about this talk, which is the title, and there's one slide that's really boring and feel free to slip into your coma for that moment or two. But it's actually really exciting to be able to talk about something that we that, I mean, people use maps for as long as there have been a way to put pictures on paper and describe things. But in terms of health care systems, it's a relatively new concept. And it ranges from fairly simple to sophisticated. And I'm going to talk a little bit about geographic information systems and research in general, but also how it's been used in trauma and then how it's influenced my own work and some of the things that have affected even the University of Chicago, but also other trauma systems around the country. So as Dr. Siegler kindly pointed out, this is, I pedigree. I've been working on stuff relatively straightforward path. I had the pleasure of being able to go to the medical ethics research meeting or meeting today and all have such amazing, rich wealth of experience in a lot of different areas and range of ages and different backgrounds and coming from different disciplines. It was wonderful to meet all of you. My path was pretty straightforward. I did the other than running out of money in college and having to take a job for a year, which was at the NIH. So it looked, even though I was washing Petri dishes essentially, but good on my med school application and probably helped me get here. It was a really sort of linear path as opposed to some of the directions that you have all taken. And I'm just, I was really humbled to be in the presence of people doing such wonderful creative things with medical ethics. So I had, you know, newly out of fellowship. I actually hadn't really thought I was going to be an academic surgeon. I went to Harvard to get a master's in public health, but I thought I would use those tools and skills to be able to develop an injury research program. Not so much injury research, but injury prevention program. And I allied myself with the preventive medicine department and met people there who ultimately became really strong mentors in research and advocacy. And one of the things that I found, along with many people, including Dr. Rogers in the room here, is that wherever we looked for disparities, we found, right? So from a social justice perspective, we looked for racial or socioeconomic disparities and outcomes, we found them. But we didn't always know why they existed. It was a black box. Cancer outcomes were worse. Trauma outcomes were worse. But why? And so in looking at different aspects of interpersonal violence, domestic violence, injury in elderly, injury in childhood, some racial and socioeconomic disparities in trauma care, I was interested to know if geographic location might influence outcomes. And certainly we know they do evolutionarily from a macrocosmic perspective, right? That's a whole principle of evolution. But what do things that are hyper-local have to do with health? And of course they do, a Flint water crisis, or high rates of pollution in New Delhi affecting hospitalizations for airway disease. Right, we know this. So how can we map it? And in the mapping of things, can we devise solutions? So geographic information systems is, it helps to visualize, analyze, interpret data to identify associations, patterns and trends and computers have really helped with this because you can put multiple layers of aggregated data to look at things like social deprivation or unemployment or even things like green spaces which have an amazing effect on occurrences of poor health outcomes. So researchers can map locations, densities and also statistically associate relationships between these things. And this is the slide. This is the boring slide of promise to you that I'd have. Because this is 98% of the work in GIS. It is looking at these address data and unless because when I started doing this GPS wasn't a thing, it hadn't been invented yet or maybe it was only being used in the military. So even now, most data is retrospective. You have address data and you have to correct in a patient database of 20,000 people every misspelled Chicago and every zip code that is 62223 as opposed to 6222223, it's agonizing. So my advice, if any of you are interested in GIS find someone to do that for you. Find a medical student, a graduate student who's willing to go through all 20,000 of these and figure out what the address is at the corner of 75th and Cottage Grove. Find just anything you can do because this is the most painful slide in the whole thing. But this, then computer programs translate to these dots and you can edit simplest, simply look visually at spatial association of patterns but you can also mathematically take into account these dots and other things by using geographic regression. So similar to putting age and race in a multivariable model, you can put geographic location into a multivariable model and look at its influence of independent effect on your outcome of interest. And that's fascinating. The fact that geography can have that much influence. So I think that maps can tell us a lot of things. It can tell us what is currently happening. So this is clearly a map of a bed and you'll notice the one thing missing from this is the actual person sleeping in the bed. But how true is this, right? And it'll take into account all of your cat's behavioral, all of your cat's behaviors and it gives you a temporal relationship too, right? Because this is the nighttime sleeping region but here is the nighttime foot is a tap zone and then here is your napping quarters especially when you wanna change the sheets on the bed which is generally in the middle of the day. So you get so much information from maps. I think they're incredible and I'm a little geeked out about this but I think maps are very informative. So when did we really start using maps for health? And this is the classic example, right? Is Sir Dr. John Snow who was looking at cases of cholera in London and he was able to by mapping the occurrences along the street trace the source to a single water pump on Broad Street because back in the day you'd have to take your bucket of water, your bucket and go fill it up at the local pump and then bring it back and do your washing and feed your kids and do all that stuff. And by using this map to demonstrate that all of these cases of cholera were occurred because all of these folks used the same pump on Broad Street, he took that information and that map to the local council and they removed the handle and stopped the outbreak. And because the UK is often better than we are kind of like Canada, which is always better than we are there is actually a memorial to this in Broad Street pump in the UK which is pretty cool. But it's been used in trauma research as well. So one of the earliest examples that I could find in the literature was in Hartford, Connecticut. These are all auto versus pedestrian incidents around Hartford. They mapped them and found that almost half of the incidents occurred on these three roadways. And what they did is brought this information to the city council and they employed traffic calming measures like speed bumps and stop signs and they effectively showed a decrease. They were able to affect a decrease in auto versus pedestrian incidents along those streets. Now what they didn't do which I thought would be really interesting is then look prospectively a year later and see if there are more auto versus pedestrian incidences and these streets that people were going to avoid going over speed bumps, right? Or if there were more, I don't know, deliberate auto versus pedestrian incidents for people sauntering out into a pedestrian walkway. Because actually when I was in Seattle one of the things that they found which was of dubious enthusiasm to the investigators is that elderly people were more likely to be hit by cars in a crosswalk than they were in non-insimilarly trafficked intersections that didn't have a crosswalk. And they didn't really wanna publicize this because crosswalks are good, right? But the problem was is that people felt safe in crosswalks. I don't really care if there's a car anywhere in them to get splattered. And so for similarly trafficked intersections if you didn't put a stop sign then people were more likely to get hit. So they ended up fixing it because Seattle, more like Canada, better than us. But it definitely was, it was definitely a finding that was concerning to the researchers. Another example is mapping burns. So the state of Utah wanted to see if there were high risk areas for burns. And they found seven high risk counties that had potentially modifiable risk factors. And these are the darker, the higher risk counties. So you'll notice some of them are centered around the urban areas and others are more rural. What do you think to make this interactive? What do you guys think? Let's see, young people in the audience. What do you think would be risk factors in Utah for burns? Young people. What's that? Camping, sure. So like open flames outside, what else? Meth. Meth, exactly. So that was the popular one in the more rural communities. And also some of the traditional, so some of these were on tribal lands and there were traditional open air cooking rituals that were being used, but which are also potentially less safe than a microwave, I guess. So meth was a big one. And if you're interested, almost, let's see, this was in 2010. In about 2013 or 14, a single pot method of creating meth was invented, which made it much safer. So you don't see anywhere near the number of meth lab explosions that there were in the past. So if you are interested in being entrepreneurial and cooking meth in your kitchen, you should go to the internet and find out the single pot method because it's statistically associated with a decrease in burns in the house. All about public health here. And the next is access to care. And again, Canada. Canada is better than we are. And that'll be a theme. And what they wanted to do is look at access to care, to see if Canadians all had access to care either within an hour by driving or an hour by air flight control. And they found that more than 90% of Canadians were able to access trauma care even if they lived in the most rural areas like Inuits and people up in the Arctic Circle. And they were using that for trauma systems planning. So all of this work had been done and I had been doing work in disparities and really looking at the geography of Chicago trauma. And wondered if there were ways to make our trauma systems practice better. And I was at Northwestern. We had a high proportion of patients. At the time, it was about 1200 patients per year, about 35% penetrating. And so we saw a lot of gunshot wounds. And I felt that our follow-up, just like everyone at any trauma surgeons in the audience, trauma follow-up, notoriously poor, right? That's something that we say. Trauma patients never follow-up. But in Northwestern, they really didn't. I don't know about where you practiced. But in Northwestern, they really didn't. But if you think about it, of course they didn't, right? Because our patients were coming from the South side and would have to take three buses and two shuttles and maybe a train to get in Northwestern for follow-up. And we did not have infrastructure. We didn't have clinics. We didn't have outreach in those areas to help provide services to our trauma patients. So the first thing we did is we wanted to look at individuals who had suffered gunshot wounds. Cause those were the folks that came from the furthest distances other than people who were traveling across in the interstate and happened to be brought to us. And what we found is these are shootings and homicides in Chicago. And this is Northwestern up here. And this is where our patients came from. You'll see the vast majority of our patients are coming from like nine, 10 miles away. In a seasoned Chicago trauma system, remember Chicago trauma systems have been around since the 1960s. We have had an organized trauma system for 50 years. And yet our patients were traveling more than 10 miles to get definitive care for potentially life-threatening injuries. But that was what it was. And we thought, how can we partner with community programs in those areas to better prevent further violence and also to better care for our patients? So we connected with community clinics in the South Side of Chicago, particularly the Southeast Side of Chicago. And we also had continuous funding for about eight years, eight or 10 years with Ceasefire, Illinois, now known as Cure Violence, who provided a hospital response model. So anytime somebody was shot, a hospital responder, an interrupter was notified. But to be fair, 90% of the time they already knew it happened. These are community embedded folks who have been given conflict mediation training and social work experience in case management experience and they would show up at the hospital and their goal was to decrease the likelihood of someone getting shot in retaliation. And this has been studied, Bureau of Justice Statistics studied it, multiple other replica sites have studied their experience and have found that in two out of three communities this can significantly decrease the likelihood of future shootings up to 60 to 70% in some communities. So it uses the credible messenger model. But I hesitate to say that this was a hospital-based violence intervention program because it wasn't. We didn't direct this, we contracted services with community members who provided this community-based resource. And these were some of our partners. It was La Rabita, the Children's Rehab Institute, Ceasefire Chicago, La Causa, which is a Latino-focused community organization, Claritian Associates. Claritian Associates works on the South Side of Chicago, affordable housing, job care, case management, and of course, Northwestern. But we were also interested not just in quality improvement and patient care. A University of Chicago medical student came to me and said, you know, I've read so much about this golden hour of trauma. Do you think it really exists? And I said, I don't know, let's look at the literature. And we looked and there was some controversy about it. A large study, large multi-centered study had come out that showed that if you were in whatever quartile of time it took to get you to the hospital, the soonest quartile or the longest quartile didn't really make a difference for any trauma patients. But in terms of outcomes for mortality. But the caveat to that was they only had about 16% trauma patients that were injured by gunshot wounds or stab wounds in their cohort. And of those, the vast majority of those patients were in urban areas where their hospital transport times were lower. So they couldn't really say anything about penetrating trauma. The other thing is that we know the outcomes are worse for rural trauma patients. A lot of that is just because, you know, test of time, right? So if you're really injured, I remember we'd have somebody trim in trees and some island off the coast of Alaska. And they'd have to be puddle jumped by some helicopter somewhere. And then six or seven more flights, they're in Anchorage. And then they come to Harborview because it was Washington, Alaska, Montana. Idaho, the four state area that we'd take care of. And I mean, maybe like 16 hours later, these people be sick as not. Maybe their initial injury score wouldn't be bad, but after getting 50 liters of crystallite in 16 hours of flights, they were really, really sick. As opposed to somebody who, you know, here falls off a trim tree. Trim trees has a couple of cracked ribs. And, you know, they're pulling 1500 on their incentive spirometer. You send them home the next day with a handful of Norco. Which is a whole other story in the whole lecture. But it was definitely difference in injury severity and it clearly impacted outcomes. So I was interested to know if this happened with penetrating trauma. And this is a map that we had created back in about 2011 or so. And these were, again, shootings around Chicago and these are trauma centers. And you'll notice that there are fair number of shootings on the west side. This kind of Austin, South Austin, that kind of area. They're handful up here by Evanston, but the majority are here on the south side and the southeast side of Chicago. But look where the trauma centers are clustered, right? And this was five years of data from Illinois State Trauma Registry. So it looked just on the surface that there might be a question to study. So the first part of the question was do people have worse outcomes if it takes longer to get to definitive care? And this was our first study that looked at that. So we used five years of data from Illinois State Trauma Registry and looked at the death rate for patients who are hypotensive and have been shot or stabbed in the chest. Bad place to be shot or stabbed. And hypotensive, low blood pressure. For those of you who aren't clinicians in the room. Low blood pressure, bad. Shot stabbed in the chest, bad unless you're lucky. And if your blood pressure's low and you have this mechanism, your likelihood of going on to die is pretty high. And if you're not hypotensive, your blood pressure's normal, then to some degree you sort of stood the test of time. And that's what these data show. So we had in that time period, this was to all the Chicago trauma centers, we had almost 1,000 patients and almost 20% of them were hypotensive, low blood pressure. And you see here that if you weren't hypotensive, if your blood pressure was normal, some of them go on to die. But there's no relationship with pre-hospital transport time. If your blood pressure is low and you're out in the field for 60 minutes, you can die. It is a predictor of mortality. And in fact, what we found was that the patients had up to a 13 fold increased incidence of dying just by being hypotensive and having a longer transport time. So that was our question. Is a longer transport time associated with higher mortality for patients with a potentially life-threatening injury? And it turned out it was. But it was only 900 patients and it really didn't ask the question for a larger audience that we wanted to know which was does distance impact that? Because we didn't look at distance in this study. It was just the map. We presumed that patients further away would have a longer transport time but we didn't know that. So around about that time, who was working on answering that question is a distance and time relationship. And that isn't as obvious as you would think. This is a 40 year, 45 plus year trauma system. Pre-hospital providers argued that they can get anyone anywhere within 10 minutes. That was the argument and that that would make no difference in mortality because no matter where you are, we can get you somewhere within 10 minutes. And we wanted to know if that was true but the question certainly wasn't settled. And around that time, Damian Turner, who was a charismatic young person, 19 years old, just graduated from high school and was an anti-violence activist. And I can't underscore this enough. This guy was doing stuff that, you know, when I was waiting tables at his age, he was working to stop human rights abuses at the Juvenile Detention Center. He traveled with Stop to New Orleans to fight against demolishment of urban public housing. He was knocking on doors to keep his own housing complex afloat in a sense of community and investing in community. He was a really dynamic kid and he got hit by a stray bullet across the street from here. And he was brought to Northwestern. His transport time was almost 40 minutes. Now he had a lethal injury. He had a non-survivable injury, penetrating wound to the chest, the back, with injuries to the orda and the superior vena cava. That was non-survivable injury in virtually anyone's hands. So he would not have survived. It was a terrible injury. But it galvanized the community and there was keen interest in the work that we were doing because of the lack of a trauma center on the southeast side of Chicago, which was where most of our catchment area was because people thought and argued rightly that a 40-minute transport time for some kid who's dying is probably too long. So we looked at 11 years of data from Illinois State Trauma Registry and looked at transport times and mortality for gunshot wounds. Unfortunately, during that time, there were almost 12,000 gunshot wounds that were brought to Illinois hospitals. Now this doesn't include people at the morgue, or people who just went to community hospitals because they were shot in the foot. These are trauma center admissions. And almost 5,000 were shot more than five miles from a trauma center. The mean transport time was higher for those who were further away, almost 17 minutes versus 10 minutes for those who were shot within that five-mile radius. And we picked five miles in an arbitrary fashion because it divided the data into one-third, two-third control, one-third case, two-third control in a nice mathematical way. But when we looked at four miles or six miles, there was a linear relationship, actually starting to be exponential relationship as well. And we found that the risk-adjusted mortality was also higher. Just by being shot more than five miles away from a trauma center, your transport time was likely to be longer and you were more likely to die, even if you control for having low blood pressure or the severity of the injury. And I don't need to tell you because you're all at University of Chicago, you know that this was a controversial and really challenging time with a lot of complex high-level discussions. This is the map that we created. This is how we used GIS for this and we used GIS for the analysis. We used the findings from our map in our regression equation. So this is the five-mile radius. And you can see that there are some high-risk areas. So this is gunshot wound mortality. There are high mortality areas but there's a lot more dark down here in these areas that are outside of the five-mile radius. In a post-hoc subset analysis, we found that these areas that are outside that radius not only are people more likely to die, they're even more likely to be male, more likely to be African-American and more likely to be uninsured in a population that is already mostly African-American, mostly uninsured and mostly male. So we are subjecting, or it is a city-wide problem that our most distressed communities are also outside of this range of trauma care that can improve mortality from gunshot wounds. So we likened it to food deserts. This was a trauma desert. So the next question was, is this a remediable situation? So what? So what if you're further away? Just drive faster or employ helicopters. And so we looked to see if this was something that could be changed. If we could eliminate these transport time disparities by simply adding another hospital in the mix. And happily, there's a natural control, right? Because the University of Chicago is a level one pediatric trauma center. So we looked at, again, unfortunately, there are so many pediatric gunshot wounds, we were able to look at pediatric gunshot wounds controlled with adult gunshot wounds. And what we found was, oops, sorry. What we found was, this is pediatric gunshot wounds. And these are trauma transport time clusters where more than 25% of the gunshot wounds experience a greater than 30 minute transport time. So it's terrible that there are any, but they're randomly distributed in the city and there aren't that many. This, on the other hand, is adults. And you can clearly see that a huge chunk of the South and Southeast side were experiencing greater than 30 minute transport times from up to like 25% or more of its transports. I mean, no one who is designing a trauma system would think that's okay. And this work was also published. And it was one of the things that the Alderman and state senators and House of Representatives of Illinois and actually national state representatives were interested in hearing. I was really careful to say this doesn't mean that a particular place should be a trauma center. All I can say is that transport times and distance from a trauma center are associated with higher mortality and we can address those transport time differences and disparities if there's another trauma center here. And there were some obviously community and civic concerns galvanized the community, but the American College of Surgeons even weighed in and said that we should put trauma centers in places that they're needed. And I think you all know the outcome of that. I was saying earlier to some of the junior faculty that it's extraordinarily gratifying to me to be able to see our research influence the potential for social change because I think this year trauma center is probably gonna save lives, but it also demonstrates an investment in the community to the University of Chicago that I don't think was there. It's engagement in the community, it's gonna provide jobs and security and save lives. And I am just so gratified that this has happened in your community and many of you made that happen. And it's also really nice because I was telling the junior faculty that I could have studied, told like receptors for the last 10 years and saw no new drugs or anything that would save anybody's lives. So it was nice to be able to see our research translated into action. And this is Dr. Rogers who just stepped out, I believe, but I really can think of no one more perfect for this job. I mean, you think about it. Guy took a demotion and probably a huge cut in pay to do the right thing for people in the community. And that's someone, I mean, you don't necessarily wanna pay him less, but it's definitely somebody that you want, somebody with an interest in this mission to change things and make things better. So what are some of the other things that we've done? In a study that was much less warmly regarded, we looked at the proximity to an establishment with the liquor license in Gunshot Wounds in Chicago. We did this using geographic regression. So we were able to control for neighborhood factors, the prevalence, the per capita incidents of Gunshot Wounds, the deprivation indices, things like female head of household, poverty indices, educational attainment. And what we found was in these dark areas, there was an up to an odds, and I've never even seen odds ratios like this. And the odds ratio of over 500 that if you're within like a half mile, like if you're within that, like actually less than half mile, it ended up being like a quarter mile of an establishment with the liquor license. It was much more likely to be shot. Our control populations or our controls were the same point in concentric circles around the area with the liquor license. And by the time you got to a quarter mile away, the association went away. So we were able to definitively show that this is a problem and Crane Chicago business just hated on this like you wouldn't believe. It was actually, but they're right because what's a solution? Do you wanna shut down a liquor store in distressed communities? And if that's the only place that people can go and congregate because there's absence of outlets for social interaction and that may be the only place that you can buy fresh fruit and vegetables in your distressed neighborhood, you don't wanna shut that down. And then what if you do? Is it just gonna move half a block over? That's what they found with a lot of community policing that they would go to a place where people congregate and then shootings would happen half a block over. So I don't have a good answer. And I certainly don't have a good economic answer, but it is clear that a liquor store in particular is associated with increased risk of firearm related violence. Again, not warmly regarded and clearly nothing has happened. So not everything leads to social change. One of the other things that we found is I worked with a woman who's done some incredible work in hospital closures, Rene Shah. And we looked at data from the state of California and I was at Martin Luther King. That was where I did my third and fourth year rotations in Los Angeles in 90, would have been 94, 95. And it was an insanely busy trauma center. It was the only level one trauma center for Compton Watts and Willowbrook. This was in the 90s when busy and it was terrible. There were little kids coming in with a hundred holes. It was the most awful thing imaginable, but they were providing good care. There was a highly publicized closure after a series of inability to meet basic standards of good care set by the Center for Medicaid and Medicare Statistics. But one of the things is that trauma care is not included in those outcomes or metrics. So the hospital was closed down and communities rallied around that because they were concerned that they were losing trauma care. And they did appoint another hospital nearby to be a level two designated center. And they worked with the city, the state, the county to ensure that the paramedics could take affected shot, car crash individuals to the nearest hospital. And they really invested a lot in that. I will give them credit. So what we found, so we looked at the neighborhoods that were served by MLK. And these are some of the other hospitals around there. These are the neighborhoods that were served by MLK. And what we found was that in general, the closure of Martin Luther King did not make a difference in trauma mortality. So this is looking at all types. So we looked at stabbings, gunshot wounds, motor vehicle collisions and pedestrian incidents and falls. And this is the observed versus expected mortality and 95% confidence intervals. So you can see over the course of time it follows the general pattern. This is the community outcomes for those zip codes that are most affected. And then these are what it would be for the whole county, like all the trauma centers in the county. However, when we looked at gunshot wounds in particular, we found that before and during the closure time, so this is when they started to close and they started to close various services of MLK and this is when it actually closed. Before and during that time, it kind of parallels the line, but then you start to see a sharp divergence of mortality for gunshot wounds after the closure of MLK. And it's hard to know if this persisted because those data aren't being collected anymore. It's also hard to know if what the underlying cause is. Is it because people are experiencing longer transport times? Is it especially in LA where the distances are so large? Or is it any number of other things? Higher lethality of weapons. Hard to imagine because this was during the peak of the effectiveness of the assault weapons ban and the Bradyville, but possible. So I don't have, I can't say causality, but I can definitely show an association and that's concerning. And interestingly, MLK is opening up as an outpatient services and arguably the thing they did best was trauma. So if they were gonna do anything, opening up a trauma center might have been a good idea. So then what am I doing in Jacksonville? So about two years ago I was recruited to be the director of research and now the associate chair for research in Jacksonville. And I'm working with a pediatric resident who's interested in pediatric surgery who is, who was interested in the pattern of gunshot wounds around Jacksonville. Because it was my observation and what people told me is that kids are getting shot in the same areas that they were shot 20 years ago. And what do you know, that's true. So while there is variation in the numbers of gunshot wounds that have occurred, there's no variation at all in the neighborhoods where kids are getting shot. These are population adjusted risk factors and they're getting shot in the same neighborhoods. This is 20 years, 20 years of difference, getting shot in the same areas. And unsurprisingly, though Jacksonville is not the most diversity in the world, most are male and most are African-American, most are assertive, very few are unintentional. And about the same mortality as you'd see anywhere else around the country. So for 20 years, map after map show the exact same neighborhoods that are being affected. Which to me says, nobody's paying attention in city and nobody really cares that kids are getting shot in the same neighborhoods over and over again. So here's another graphic representation of that. This is a deprivation index that's been applied to the city of Jacksonville. And this takes into account things like socioeconomic status, housing availability, food deserts, education, employment. And I know this won't come as a shock to anyone. It's the same neighborhoods. So our hope is that this will be presented and published and we'll have some items of discussion for the city legislature. So I'm also working with Florida Health, I'm the chair of the Data and Surveillance Committee. There've also been some concerns about expansions of for-profit level two trauma centers in the state. Of Florida and effects on cost of care and injury outcomes. But the geography of structural violence and health disparities is a huge untapped area for research and I'm very interested in working with anyone in any city who's interested in looking in those topics. And finally, when I've been called to consult with Columbia University to examine associations between willingness to travel and cancer care outcomes for the state of New York, which I think is interesting because rural people and urban people have different thoughts and we know outcomes are better at centers of excellence for patients with cancer, but why won't people go? So triangulating the data with location and with attitudes surveyed, I think it'll be really fascinating. So just to end on a lighter note, this is my favorite map joke ever. For heaven's sake, Elroy, now look where the earth is. Move over and let me drive. Because this is medical ethics focused, I put a couple of questions up there about the ethics of this. So was it ethical to focus on trauma systems instead of primary prevention? So there's still 12, if there's 12,000 gunshot wounds and we help a couple of kids survive, yay, great, but there's still 12,000 gunshot wounds. Maybe I should be looking at something else. And then how ethical was it to testify about our research? Again, I was careful to say this is research about trauma systems and I'm not positing that outcomes will be better based on any solutions you may have, but I did testify. And then requests from other researchers to access our data. I got at least three calls from people saying, I don't believe you, I wanna look at your data. And as a relatively, you know, it's got an early mid-career at that point, I wasn't sure how to handle that. I mean, happily the memorandum of understanding said pretty clearly I can't share the data. And if you want those data, you have to go to the state of Illinois and request them yourself and go through the year-long process of getting it. But it was interesting and people were asking me in a fairly hostile sort of way. But those were some ethical dilemmas I experienced which is doing the research. But with that, I will end and ask for any comments or questions. Yeah, not initially. So initially it was a pretty straightforward process to just give my research plan to Illinois Department of Public Health when they provided the data, which was great. I think they were less happy when they discovered the results of our research. But by then it was sort of too late. Interestingly, IDPH had then imploded and they were no longer maintaining this registry. I don't know if that's recovered in the last two years but as of like 2014 and 2015, they weren't, we can't check this anymore. We don't have this level of granularity which is disappointing because it was really rich. Sure, so we estimated, and we just did this with mathematical modeling, we estimated that about eight fewer people per year would die in the city of Chicago based on having an additional trauma center. So then we calculated the amount of money, but the value of a life in actuarial terms to be $150,000 to $200,000. And it turned out to be that that was less than the cost of the initial funding of a trauma center. Per life year, yeah. Yeah, so it turned out to be less than the cost of the trauma center which I don't know if it was persuasive but that was the thought. About 80% of the per trauma center you're in to change it from a desert to an act program, you would use that as fighting? That it would be eight people per year based on the number of people expected to be shot per year. That was what we figured out because there'd be a 23% less likely to die. So based on the typical injury severity, the typical number of people shot in that neighborhood that we're experiencing higher mortality than they otherwise would, that it would end up being about eight patients per year that would live who would have otherwise died. But again, that's an estimate and would have to be looked at prospectively. A paper awaiting the dangers come through three years later. Yeah, yeah we did include that as like one sentence in our paper that was about it. I think there was a hand up back there. Yeah, so this is a two-part question. Just clarification for the licensor, for the liquor license, if it was any like a beverage liquor license or like a restaurant or a grocery store type thing. There were anything, it was a packaged liquor store versus tavern and those were compared with like grocery stores and it was very neighborhood specific. I don't know if you saw the map but you could be downtown and be right next to a bar and there was no increased risk at all and for the overall city of Chicago there was no increased risk. So, but even when you controlled for areas of higher deprivation, higher stress and higher baseline number of people who were shot that still increased the likelihood of being shot over 500 fold. Okay, thank you. And then the second question was in regards I'm a statistician so I'm more into about like the data. In terms of the collection of data you said out of the state of Illinois, did you use any hospital data or was it just public or government data? The hospitals in the state of Illinois trauma systems are maintained by the Illinois Department of Public Health so they had done the certification for trauma centers. So the accreditation of all these trauma centers was that and each of those trauma centers that are accredited by the state submit their data to state. So it is hospital data maintained by the state but everything came originally from each trauma center, patient level. Any other questions? Thank you so much for your attention. I really appreciate it. Thanks for the opportunity to be here.