PUBLIC HEALTH UPDATE: Gun Violence and Public Health

Matt Willis, MD, MPH

Because the theme of this issue is Emergency Medicine, it seems appropriate to address one of the most important preventable sources of injury and death in America today. According to the CDC’s National Center for Health Statistics, gun violence kills more than 33,000 people a year in the United States, nearly as many as motor vehicle accidents.¹ The Marin Medical Society, the California Medical Association and the American Medical Association have long advocated reasonable and responsible gun control legislation to make our communities safer and hospitals less crowded.

Many are calling for gun violence to be seen as a national public health priority. What do we gain by framing gun violence as a public health issue, in addition to a law enforcement and public safety issue? First, as a branch of   health science, public health relies on research and data to inform practice. This can lift dialogue out of entrenched partisan lines and elevate evidence-based understanding. The available data is sobering.

In California, 2,900 people died by firearms in 2013. About half were suicides (54%), the other half (45%) were assaults.² Another 2,650 were hospitalized and survived, and 3,385 went to the Emergency Department and survived.³  

Unfortunately, longstanding restrictions on the ability to research and monitor the role of guns in deaths and injuries make it difficult to measure their true impact and refine our strategies. In June, AMA President Dr. Steven Stack said, “Even as America faces a crisis unrivaled in any other developed country, Congress prohibits the CDC from conducting the very research that would help us understand the problems associated with gun violence.”⁴

When research is conducted, the scope of the problem becomes clearer. A recent JAMA study described⁵ 29,000 Denver-area emergency department patients treated for gunshot wounds between 2000 and 2013 and found that the fatality rate increased significantly over that period. The authors concluded that guns are “becoming progressively more dangerous.” Research like this is invaluable in guiding policies regarding access to particularly deadly classes of firearms.

A study published in NEJM found that living in a home where guns are kept increased an individual’s risk of death by homicide by between 40% and 170%.⁶ Another study published in the American Journal of Epidemiology similarly found that “persons with guns in the home were at 90 percent greater risk of dying from a homicide in the home than those without guns in the home.”⁷ Such findings add an evidence-base for clinical practice to screen families for guns in the home and counsel on their safe handling and storage.

Instead of waiting for a federal response to the call for high-quality research, California and other states are taking action. Senate Bill 1006, passed this summer, will fund a new gun violence research program and center at UC Davis. The program will focus on both the causes and consequences of gun violence as well as the effectiveness of existing laws. A $5 million appropriation will fund the gun violence center’s first five years of operation.

The CMA and the Health Officers Association of California strongly supported the bill. CMA President Dr. Steven Larson said, “SB 1006 creates a research center within the University of California that will allow this state to do this very research and provide California with the analysis it needs to fully address this public health crisis.”

Beyond highlighting the need for research and data-driven solutions, a public health approach to gun violence acknowledges the array of factors behind this complex epidemic. In national dialogue following the recent Orlando massacre, three dominant themes have emerged regarding preventing mass shootings. While some focus blame on one or another of these issues, each must be addressed simultaneously and in parallel before we can feel safe from the threat of firearms.

These themes are (a) guns—including their availability, design, sales, regulation and capacity for harm; (b) the mental status of the shooter—including the degree to which mental state can be assessed and violence predicted and prevented; and (c) the social context—including the environment of the shooting and the broader cultural values, norms and social contracts that guide our behavior in everyday life, and in particular the use of arms.  

Guns
According to the AMA, “uncontrolled ownership and use of firearms, especially handguns, is a serious threat to the public’s health inasmuch as the weapons are one of the main causes of intentional and unintentional injuries and deaths.”⁸

This position mirrors one of the core principles of public health practice. The removal of potential sources of harm from our shared environment is a primary tool of public health. In the healthiest communities, the choices that individuals make in their daily routines have been shaped toward health, often as the result of policy. For example, due to the clear evidence of the benefit of seat belts, we do not have the legal choice to drive without them. The choice to light up a cigarette has been severely restricted because of the harm smoking is known to cause.

The evidence is clear that owning a gun makes us less safe. Households with a gun are more likely to experience gun-related injury or death than gun-free households, most often by household members on one another or themselves.⁹ Reducing the presence of guns in our shared environment fits logically into the public health mandate. The choice to use a gun when spurred by a violent impulse is one that— due to its irreversible consequences—we would live better and longer without.

We’re fortunate in Marin that our district attorney has conducted several successful gun buy-back programs, which effectively remove several hundred firearms from our community every year. While such efforts to reduce the approximately 3 million firearms in American households are vital, they are not enough.

Currently the AMA supports a waiting period before someone can purchase any form of firearm, background checks for all handgun purchasers, stricter enforcement of present federal and state gun safety legislation, and mandated additional penalties for crimes committed with a firearm, including illegal possession.  

Mental health
Some responses to recent mass shootings focus on the mental health of the shooter. Some gun lobbyists suggest the primary solution is making gun ownership illegal for all those with mental illness. The U.S. Department of Health and Human Services reports that one in four adults—approximately 60 million Americans—experience a mental health disorder in any given year. One in 25 Americans lives with a serious mental illness such as schizophrenia, major depression or bipolar disorder.¹⁰ Clearly, most of these people are not violent, and most violent crimes are committed by those with no psychiatric history.

Marin County averaged 14 gun-related deaths annually from 2009 to 2014. Of these, 84% were suicides.¹¹ Controlling gun violence locally clearly relies on mental health approaches to suicide prevention, as well as decreased access to guns.

So, while mental illness is clearly not the sole cause of gun violence or mass shootings, this is an opportunity to shine light on the reality that many people living with mental illness are not identified or provided with the treatment they need. We need consistent support for programs for early detection of mental illness or its precursors in schools, and for the Affordable Care Act’s prioritizing mental health services in primary care settings.  

Social context
While Americans represent less than 5% of the world’s population, the U.S. is home to between 35% and 50% of all civilian-owned guns—with an estimated 89 guns for every 100 civilians.¹² It should come as no surprise then that the U.S. has more gun violence, gun crimes and gun deaths than any other country. The media’s routine reporting of this violence normalizes it, for some, as a way to resolve disputes. Health care providers and public health agencies share a role to educate the community on the dangers of guns in the home. Some states have passed laws that limit physicians’ ability to screen families for guns in the home or to counsel parents on the safe handling and storage of guns. This highlights the need for clinicians to remain aware of political and social factors that determine medical practice, and speak out against policies that threaten evidence-based care.

The approach to gun violence is an area where our medical societies and the county public health agency are clearly aligned. We recognize shared responsibility in creating an environment in which people can live healthy lives. Medical societies and public health advocates must support strengthening gun violence research and evidence-based control laws. We can use our voices to challenge the social norm of accepting the ubiquity of arms.

Physicians are too often firsthand witnesses to the damage of gun violence —to the victims, their families and our communities. Putting political differences aside, as local stewards of public health we should respond to these daily tragedies with honest outrage over the availability and routine use of firearms against ourselves and one another. A public health approach to gun violence, fueled by physicians’ firsthand experiences, can move public dialogue toward policies and practices that will make our communities safer. 

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Dr. Willis is Marin County’s public health officer.
Email: mwillis@marincounty.org

References

1. CDC, “National Vital Statistics Reports,” NCHS Vol. 64, No. 2, p. 10, www.cdc. gov/nchs/data/nvsr/nvsr64/nvsr64_02. pdf (2016; statistics for 2013).
2. CDPH, Vital Statistics Death Statistical Master Files; report generated from http://epicenter.cdph.ca.gov (9/12/16).
3. CDPH, California Office of Statewide Health Planning and Development, Inpatient Discharge Data; report generated from http://epicenter.cdph.ca.gov (9/12/16).
4. AMA, “AMA Calls Gun Violence ‘A Public Health Crisis;’ Will Actively Lobby Congress to Lift Ban on CDC Gun Violence Research,” www.ama-assn.org/ama/ pub/news/news/2016/2016-06-14-gunviolence-lobby-congress.page (2016).
5. Sauaia A, et al, “Fatality and Severity of Firearm Injuries in a Denver Trauma Center, 2000–2013,” JAMA 315(22):24652467 (2016).
6. Wintemute G, “Guns, Fear, the Constitution, and the Public’s Health,” 358 NEJM 1421-1424 (2008).
7. Dahlberg L, et al, “Guns in the Home and Risk of a Violent Death in the Home: Findings from a National Study,” 160 Am J Epidemiology 929, 935 (2004).
8. AMA, “AMA Calls Gun Violence ‘A Public Health Crisis;’ Will Actively Lobby Congress to Lift Ban on CDC Gun Violence Research,” www.ama-assn.org/ama/ pub/news/news/2016/2016-06-14-gunviolence-lobby-congress.page (2016).
9. Dahlberg L, et al, “Guns in the Home and Risk of a Violent Death in the Home: Findings from a National Study,” 160 Am J Epidemiology 929, 935 (2004).
10. NIMH, “Serious Mental Illness (SMI) Among U.S. Adults,” www.nimh.nih. gov/health/statistics/prevalence/seriousmental-illness-smi-among-us-adults. shtml (2014 data).
11. CDPH, Vital Statistics Death Statistical Master Files; report generated from http://epicenter.cdph.ca.gov (9/12/16).
12. Graduate Institute of International Studies, Geneva, “Small Arms Survey 2007: Guns and the City,” 39 (Aug 2007).