A public health approach to gun violence

 

In 2014, 33,594 people were killed by firearms in the United States. More than 21,000 of these deaths were suicides. The rest were primarily homicides and accidental shootings. Meanwhile, firearm deaths represented nearly 17% of injury deaths that year.^1,2

In a 2015 Perspective published in the New England Journal of Medicine, author Chana Sacks, MD, pointed out that 20 children and adolescents are sent to the hospital daily for firearm injuries and 2,000 people each year suffer gunshot-related spinal cord injuries and “become lifelong patients.”³

At the same time, Federal Bureau of Investigation data show that the number of active shooter situations rose between 2000 and 2013, with an average of 6.4 incidents a year for the first 7 years of the study, conducted in 2013, and an average of 16.4 in the last 7 years of the study. More than 1,000 people were wounded or killed across 160 active shooter incidents, defined as an individual or individuals actively engaged in killing or trying to kill people in a populous area.⁴

“Gun violence is undeniably a public health issue,” said Dr. Sacks, a hospitalist at Massachusetts General Hospital and instructor at Harvard Medical School, both in Boston, and a vocal proponent of addressing firearms in the public health sphere. Her cousin’s 7-year-old son, Daniel Barden, was fatally shot at Sandy Hook Elementary School in Newtown, Conn., in December 2012.

Yet, the notion of firearm injuries and deaths as a public health issue is, in America, an issue of contention. How can hospitalists and other health care providers avoid wading into the political thicket while also looking out for their patients?

For one, it’s not the only controversial issue with which providers are confronted, Dr. Sacks and others say. From taking sexual histories, counseling patients about abortion and adoption, and discussing end-of-life issues, clinicians may routinely face uncomfortable interactions in the name of patient care.

“It’s not a question about their right to a weapon; it’s about how individuals can stay as safe as possible and keep their families as safe as possible,” said Dr. Sacks, who also wrote in a January 2017 opinion for the American Medical Association that: “Counseling about gun safety is not political – no more so than a physician counseling a patient about cutting down on sugary beverages is an act of declaring support for New York City’s attempted ban on large-sized sodas.”⁵

 

This idea is echoed by David Hemenway, PhD, director of the Harvard Injury Control Research Center, Boston. “You can talk about wearing your seat belt without advocating for mandatory seat belt laws,” he said.

Yet in a 2014 survey of internist members of the American College of Physicians, only 66% of respondents said they believed physicians have the right to counsel patients on gun violence prevention and 58% said they never ask patients about guns in their home. That same survey showed the public is also split: While two-thirds of respondents said it was at least sometimes appropriate for providers to ask about firearms during a visit, one-third believed it was never appropriate.⁶

In fact, Barbara Meyer, MD, MPH, a family physician in Seattle, said she once had a patient walk out of the office when he encountered a question about firearms on the intake forms for the health system at which she was employed at the time. Today, at NeighborCare Health, the presence of firearms in the home is a question in the well-child electronic health record.

The Harvard Injury Control Research Center runs a campaign called Means Matter, designed to address suicide by firearm, the most common method of suicide in America. The campaign – backed by decades of some of the best research available – reports that people die of suicide by gun more than all other methods combined, that suicide attempts using a firearm are almost always fatal, and that firearms used by youths who commit suicide almost always belong to a parent.

 

“Suicide is often an impulsive act,” said Dr. Sacks, which means preventing access to firearms for patients at risk can be a matter of life and death. “There is potential for intervention there … what can be more clearly medical than suicide prevention?”

For her, that means eliminating the partisan component and equipping providers with the best evidence-based research available and with best practices. Reliable studies show that having guns at home increases the danger to families, said Dr. Hemenway, and places with fewer guns and stronger gun laws are correlated with fewer gun fatalities.^7,8

“In accordance with guidelines and the best evidence out there, we should be screening patients who might be at risk for gun violence,” he said. “In some cases, interventions can be as simple and straightforward as informing patients where to get gun locks and talking to them about how to store firearms safely.”

At Massachusetts General Hospital, Dr. Sacks helped found the Gun Violence Prevention Coalition, an interdisciplinary group of physicians, nurses, physical therapists, and others committed to raising awareness and preparing providers to address gun violence. She believes strongly that physicians can act locally to help address the issue.

 

In Seattle, Dr. Meyer has been involved with a local group called Washington Ceasefire, prompted both by her experience as a resident in Detroit – where she was routinely exposed to the traumas of gun violence – as well as a shooting that occurred outside her daughter’s high school in Seattle years ago. The group has recently begun advocating for smart guns, which are designed to be fired only by an authorized user.

Indeed, Dr. Hemenway said research by his group suggests 300,000-500,000 guns are stolen every year, though he points out that we know almost nothing about “who, what, when, why, and where.” That’s largely because of an effective ban on gun violence research, enacted by Congress in the 1990s.⁹

“It’s not like there’s no evidence, but compared to the size of the problem, you want good evidence,” Dr. Hemenway said. “America has lots of guns. How can we learn to live with them?”

Gun violence affects not just those shot and killed by firearms, but also those affected by the trauma it can leave in its wake. Dr. Sacks recounts a recent visit to Massachusetts General by survivors of the Pulse Nightclub shooting in Orlando, Fla., which took place on June 12, 2016.

 

“It was a moving, intense event where we all sat around and talked about this issue,” Dr. Sacks said. “The number of people dying is horrific enough, but it’s not just that. Here were a number of young people who survived and yet whose lives will never be the same. We are undercounting the number of people affected by gun violence.”

Studies also estimate the cost of medical care related to gun violence to be roughly $620 million per year, averaging between $9,000 and $18,000 per patient in 2014.¹⁰

Despite some arguments to the contrary, addressing gun violence as a public health issue is not a distraction from other important public health issues such as opioid abuse. “It is entirely a false choice that we must only take on one issue or another,” Dr. Sacks said.

Nor should efforts to address gun violence focus only on individuals, said Dr. Hemenway, who told the Harvard T.H. Chan School of Public Health in October 2017 that: “A lesson from public health is that it is usually more effective to change the environment than to try to change people. The U.S. should use the same harm reduction approach to gun violence that it uses to treat other public health threats, like automobile crashes or air pollution, employing a wide variety of methods to reduce the problem.”

The issue must be reframed, said Dr. Sacks. This remains one of her biggest goals. “If we can find a way to act and intervene and lower [the] number [of people affected by gun violence], what could be more fundamentally in line with what we try to do every day as physicians?” she asked. “How can we reduce morbidity and mortality? That’s an answerable question and we can make sure we have pathways and approaches we can put in place to understand this. This is a solvable problem.”

 

 

In 2014, 33,594 people were killed by firearms in the United States. More than 21,000 of these deaths were suicides. The rest were primarily homicides and accidental shootings. Meanwhile, firearm deaths represented nearly 17% of injury deaths that year.^1,2

In a 2015 Perspective published in the New England Journal of Medicine, author Chana Sacks, MD, pointed out that 20 children and adolescents are sent to the hospital daily for firearm injuries and 2,000 people each year suffer gunshot-related spinal cord injuries and “become lifelong patients.”³

At the same time, Federal Bureau of Investigation data show that the number of active shooter situations rose between 2000 and 2013, with an average of 6.4 incidents a year for the first 7 years of the study, conducted in 2013, and an average of 16.4 in the last 7 years of the study. More than 1,000 people were wounded or killed across 160 active shooter incidents, defined as an individual or individuals actively engaged in killing or trying to kill people in a populous area.⁴

“Gun violence is undeniably a public health issue,” said Dr. Sacks, a hospitalist at Massachusetts General Hospital and instructor at Harvard Medical School, both in Boston, and a vocal proponent of addressing firearms in the public health sphere. Her cousin’s 7-year-old son, Daniel Barden, was fatally shot at Sandy Hook Elementary School in Newtown, Conn., in December 2012.

Yet, the notion of firearm injuries and deaths as a public health issue is, in America, an issue of contention. How can hospitalists and other health care providers avoid wading into the political thicket while also looking out for their patients?

For one, it’s not the only controversial issue with which providers are confronted, Dr. Sacks and others say. From taking sexual histories, counseling patients about abortion and adoption, and discussing end-of-life issues, clinicians may routinely face uncomfortable interactions in the name of patient care.

“It’s not a question about their right to a weapon; it’s about how individuals can stay as safe as possible and keep their families as safe as possible,” said Dr. Sacks, who also wrote in a January 2017 opinion for the American Medical Association that: “Counseling about gun safety is not political – no more so than a physician counseling a patient about cutting down on sugary beverages is an act of declaring support for New York City’s attempted ban on large-sized sodas.”⁵

 

This idea is echoed by David Hemenway, PhD, director of the Harvard Injury Control Research Center, Boston. “You can talk about wearing your seat belt without advocating for mandatory seat belt laws,” he said.

Yet in a 2014 survey of internist members of the American College of Physicians, only 66% of respondents said they believed physicians have the right to counsel patients on gun violence prevention and 58% said they never ask patients about guns in their home. That same survey showed the public is also split: While two-thirds of respondents said it was at least sometimes appropriate for providers to ask about firearms during a visit, one-third believed it was never appropriate.⁶

In fact, Barbara Meyer, MD, MPH, a family physician in Seattle, said she once had a patient walk out of the office when he encountered a question about firearms on the intake forms for the health system at which she was employed at the time. Today, at NeighborCare Health, the presence of firearms in the home is a question in the well-child electronic health record.

The Harvard Injury Control Research Center runs a campaign called Means Matter, designed to address suicide by firearm, the most common method of suicide in America. The campaign – backed by decades of some of the best research available – reports that people die of suicide by gun more than all other methods combined, that suicide attempts using a firearm are almost always fatal, and that firearms used by youths who commit suicide almost always belong to a parent.

 

“Suicide is often an impulsive act,” said Dr. Sacks, which means preventing access to firearms for patients at risk can be a matter of life and death. “There is potential for intervention there … what can be more clearly medical than suicide prevention?”

For her, that means eliminating the partisan component and equipping providers with the best evidence-based research available and with best practices. Reliable studies show that having guns at home increases the danger to families, said Dr. Hemenway, and places with fewer guns and stronger gun laws are correlated with fewer gun fatalities.^7,8

“In accordance with guidelines and the best evidence out there, we should be screening patients who might be at risk for gun violence,” he said. “In some cases, interventions can be as simple and straightforward as informing patients where to get gun locks and talking to them about how to store firearms safely.”

At Massachusetts General Hospital, Dr. Sacks helped found the Gun Violence Prevention Coalition, an interdisciplinary group of physicians, nurses, physical therapists, and others committed to raising awareness and preparing providers to address gun violence. She believes strongly that physicians can act locally to help address the issue.

 

In Seattle, Dr. Meyer has been involved with a local group called Washington Ceasefire, prompted both by her experience as a resident in Detroit – where she was routinely exposed to the traumas of gun violence – as well as a shooting that occurred outside her daughter’s high school in Seattle years ago. The group has recently begun advocating for smart guns, which are designed to be fired only by an authorized user.

Indeed, Dr. Hemenway said research by his group suggests 300,000-500,000 guns are stolen every year, though he points out that we know almost nothing about “who, what, when, why, and where.” That’s largely because of an effective ban on gun violence research, enacted by Congress in the 1990s.⁹

“It’s not like there’s no evidence, but compared to the size of the problem, you want good evidence,” Dr. Hemenway said. “America has lots of guns. How can we learn to live with them?”

Gun violence affects not just those shot and killed by firearms, but also those affected by the trauma it can leave in its wake. Dr. Sacks recounts a recent visit to Massachusetts General by survivors of the Pulse Nightclub shooting in Orlando, Fla., which took place on June 12, 2016.

 

“It was a moving, intense event where we all sat around and talked about this issue,” Dr. Sacks said. “The number of people dying is horrific enough, but it’s not just that. Here were a number of young people who survived and yet whose lives will never be the same. We are undercounting the number of people affected by gun violence.”

Studies also estimate the cost of medical care related to gun violence to be roughly $620 million per year, averaging between $9,000 and $18,000 per patient in 2014.¹⁰

Despite some arguments to the contrary, addressing gun violence as a public health issue is not a distraction from other important public health issues such as opioid abuse. “It is entirely a false choice that we must only take on one issue or another,” Dr. Sacks said.

Nor should efforts to address gun violence focus only on individuals, said Dr. Hemenway, who told the Harvard T.H. Chan School of Public Health in October 2017 that: “A lesson from public health is that it is usually more effective to change the environment than to try to change people. The U.S. should use the same harm reduction approach to gun violence that it uses to treat other public health threats, like automobile crashes or air pollution, employing a wide variety of methods to reduce the problem.”

The issue must be reframed, said Dr. Sacks. This remains one of her biggest goals. “If we can find a way to act and intervene and lower [the] number [of people affected by gun violence], what could be more fundamentally in line with what we try to do every day as physicians?” she asked. “How can we reduce morbidity and mortality? That’s an answerable question and we can make sure we have pathways and approaches we can put in place to understand this. This is a solvable problem.”

 

 

In 2014, 33,594 people were killed by firearms in the United States. More than 21,000 of these deaths were suicides. The rest were primarily homicides and accidental shootings. Meanwhile, firearm deaths represented nearly 17% of injury deaths that year.^1,2

In a 2015 Perspective published in the New England Journal of Medicine, author Chana Sacks, MD, pointed out that 20 children and adolescents are sent to the hospital daily for firearm injuries and 2,000 people each year suffer gunshot-related spinal cord injuries and “become lifelong patients.”³

At the same time, Federal Bureau of Investigation data show that the number of active shooter situations rose between 2000 and 2013, with an average of 6.4 incidents a year for the first 7 years of the study, conducted in 2013, and an average of 16.4 in the last 7 years of the study. More than 1,000 people were wounded or killed across 160 active shooter incidents, defined as an individual or individuals actively engaged in killing or trying to kill people in a populous area.⁴

“Gun violence is undeniably a public health issue,” said Dr. Sacks, a hospitalist at Massachusetts General Hospital and instructor at Harvard Medical School, both in Boston, and a vocal proponent of addressing firearms in the public health sphere. Her cousin’s 7-year-old son, Daniel Barden, was fatally shot at Sandy Hook Elementary School in Newtown, Conn., in December 2012.

Yet, the notion of firearm injuries and deaths as a public health issue is, in America, an issue of contention. How can hospitalists and other health care providers avoid wading into the political thicket while also looking out for their patients?

For one, it’s not the only controversial issue with which providers are confronted, Dr. Sacks and others say. From taking sexual histories, counseling patients about abortion and adoption, and discussing end-of-life issues, clinicians may routinely face uncomfortable interactions in the name of patient care.

“It’s not a question about their right to a weapon; it’s about how individuals can stay as safe as possible and keep their families as safe as possible,” said Dr. Sacks, who also wrote in a January 2017 opinion for the American Medical Association that: “Counseling about gun safety is not political – no more so than a physician counseling a patient about cutting down on sugary beverages is an act of declaring support for New York City’s attempted ban on large-sized sodas.”⁵

 

This idea is echoed by David Hemenway, PhD, director of the Harvard Injury Control Research Center, Boston. “You can talk about wearing your seat belt without advocating for mandatory seat belt laws,” he said.

Yet in a 2014 survey of internist members of the American College of Physicians, only 66% of respondents said they believed physicians have the right to counsel patients on gun violence prevention and 58% said they never ask patients about guns in their home. That same survey showed the public is also split: While two-thirds of respondents said it was at least sometimes appropriate for providers to ask about firearms during a visit, one-third believed it was never appropriate.⁶

In fact, Barbara Meyer, MD, MPH, a family physician in Seattle, said she once had a patient walk out of the office when he encountered a question about firearms on the intake forms for the health system at which she was employed at the time. Today, at NeighborCare Health, the presence of firearms in the home is a question in the well-child electronic health record.

The Harvard Injury Control Research Center runs a campaign called Means Matter, designed to address suicide by firearm, the most common method of suicide in America. The campaign – backed by decades of some of the best research available – reports that people die of suicide by gun more than all other methods combined, that suicide attempts using a firearm are almost always fatal, and that firearms used by youths who commit suicide almost always belong to a parent.

 

“Suicide is often an impulsive act,” said Dr. Sacks, which means preventing access to firearms for patients at risk can be a matter of life and death. “There is potential for intervention there … what can be more clearly medical than suicide prevention?”

For her, that means eliminating the partisan component and equipping providers with the best evidence-based research available and with best practices. Reliable studies show that having guns at home increases the danger to families, said Dr. Hemenway, and places with fewer guns and stronger gun laws are correlated with fewer gun fatalities.^7,8

“In accordance with guidelines and the best evidence out there, we should be screening patients who might be at risk for gun violence,” he said. “In some cases, interventions can be as simple and straightforward as informing patients where to get gun locks and talking to them about how to store firearms safely.”

At Massachusetts General Hospital, Dr. Sacks helped found the Gun Violence Prevention Coalition, an interdisciplinary group of physicians, nurses, physical therapists, and others committed to raising awareness and preparing providers to address gun violence. She believes strongly that physicians can act locally to help address the issue.

 

In Seattle, Dr. Meyer has been involved with a local group called Washington Ceasefire, prompted both by her experience as a resident in Detroit – where she was routinely exposed to the traumas of gun violence – as well as a shooting that occurred outside her daughter’s high school in Seattle years ago. The group has recently begun advocating for smart guns, which are designed to be fired only by an authorized user.

Indeed, Dr. Hemenway said research by his group suggests 300,000-500,000 guns are stolen every year, though he points out that we know almost nothing about “who, what, when, why, and where.” That’s largely because of an effective ban on gun violence research, enacted by Congress in the 1990s.⁹

“It’s not like there’s no evidence, but compared to the size of the problem, you want good evidence,” Dr. Hemenway said. “America has lots of guns. How can we learn to live with them?”

Gun violence affects not just those shot and killed by firearms, but also those affected by the trauma it can leave in its wake. Dr. Sacks recounts a recent visit to Massachusetts General by survivors of the Pulse Nightclub shooting in Orlando, Fla., which took place on June 12, 2016.

 

“It was a moving, intense event where we all sat around and talked about this issue,” Dr. Sacks said. “The number of people dying is horrific enough, but it’s not just that. Here were a number of young people who survived and yet whose lives will never be the same. We are undercounting the number of people affected by gun violence.”

Studies also estimate the cost of medical care related to gun violence to be roughly $620 million per year, averaging between $9,000 and $18,000 per patient in 2014.¹⁰

Despite some arguments to the contrary, addressing gun violence as a public health issue is not a distraction from other important public health issues such as opioid abuse. “It is entirely a false choice that we must only take on one issue or another,” Dr. Sacks said.

Nor should efforts to address gun violence focus only on individuals, said Dr. Hemenway, who told the Harvard T.H. Chan School of Public Health in October 2017 that: “A lesson from public health is that it is usually more effective to change the environment than to try to change people. The U.S. should use the same harm reduction approach to gun violence that it uses to treat other public health threats, like automobile crashes or air pollution, employing a wide variety of methods to reduce the problem.”

The issue must be reframed, said Dr. Sacks. This remains one of her biggest goals. “If we can find a way to act and intervene and lower [the] number [of people affected by gun violence], what could be more fundamentally in line with what we try to do every day as physicians?” she asked. “How can we reduce morbidity and mortality? That’s an answerable question and we can make sure we have pathways and approaches we can put in place to understand this. This is a solvable problem.”