It kills more than 31,000 Americans a year, a scourge with a toll greater than that of HIV/AIDS. More people die from this disease each year than from alcoholic liver failure and skin cancer combined. Despite this, since 1997, the U.S. government has spent virtually no money on researching its prevention.
The disease is gun violence.
Like millions of American parents, in December I choked back tears, harnessed emotions, and prepared to speak to my second-grader about Newtown. Despite my disgust and bewilderment, I planned to present a measured explanation. “Sometimes people do horrible things, but all things considered, schools are safe, you are safe, and we will do everything in our power to keep you safe.”
But behind the sane façade, my blood boiled. How can this continue to happen in our society — Virginia Tech, Aurora, Clackamas, and so many more? Unfortunately, such tragic news tends to do little to bring an actual solution when it comes to gun violence. Most people, on the contrary, just use these events to bulwark what they already believe. Gun control activists argued after Newtown that tighter gun control would have prevented this tragedy; gun rights activists bemoaned restrictions on concealed weapons on school grounds; others claimed additional culprits — video games, movies, major holes in mental care services.
Ultimately, not much will change and the body count will continue to mount if the past is a predictor, despite the political swirl of the past couple of months. But what if we committed to looking at gun violence differently? What if we analyzed it not as a political issue and not as matter of varied opinion but as a public health matter? This concept has received some media attention in the past couple of months, but it is not at all a novel one. It has been endorsed by the World Health Organization and by emergency medicine public health leaders such as Arthur Kellermann, MD, and Garen Wintemute, MD.
Like many other health professionals, I believe that bullets should be viewed as pathogens, like bacteria and tumors. If we view the problem through this lens, the question becomes, simply, how we can mitigate the effect of the bullet? We know that the aggregate medical opinion is quite clear; the best way to treat a victim of a gunshot wound is to prevent the gunshot from happening. For those who might contest semantics, I argue that it does not really matter if you say that bullets kill people or people kill people; the fact is more than 31,000 deaths a year are caused by the destructive properties of bullets.
From a public health standpoint, this circumstance (a person firing a bullet) itself is a pathogen that, more than just about any other, needs to be prevented rather than treated after the fact. Contrast this with other destructive acts, such as stabbings and overdoses, that are much easier to treat after they occur. This is self-evident to emergency physicians in our clinical experience: our patients who attempt suicide by overdose tend to have far better clinical outcomes than those who do the same by bullet.
It is a simple observation that no one dies from a bullet that isn't fired, but it is one to which our public policy has not been attuned. If you have any doubt, consider a similar debate 50 years ago. It was a time when the nation's roadways were unregulated death traps, but many people voiced concerns that improvements in highway safety were unnecessary impingements on freedom. Still, over time, we have come to appreciate that speed limits, traffic safety signs, seatbelts, and airbags save lives. Road-related fatalities per capita have drifted consistently down, and this past year is expected to be the first in modern history in which there were more bullet-related deaths than motor-vehicle related ones.
You may then be surprised to learn that despite our amazing success in preventing road-related deaths and despite the significant toll of bullet-related violence on our society, political pressure has led to a moratorium on federal research spending on gun violence prevention. The details of this circumstance have been described elsewhere (read the Washington Post editorial by Jay Dickey and Mark Rosenberg at http://bit.ly/XGmdl1), but the gist is that the National Rifle Association (NRA) in 1996 successfully backed efforts to remove funding from the CDC after CDC-supported research reported an increased risk of death (rather than a protective effect) from owning a firearm in the home.
The funding extraction later extended to other agencies like the National Institutes of Health. Some private foundations stepped in to fill the void, but the message to the scientific community was heard loud and clear: there is little to no money to support research into gun violence prevention. Investigations in this field have slowed to a trickle over the past 15 years while the federal government funds some $240 million a year in traffic safety research. Wouldn't it be helpful if we could look closely at some of the critical questions surrounding the prevention of gun violence? Here are some that strike me as keenly important.
- What are the most effective gun safety interventions? Warning labels, training classes, medical or psychiatric screening programs? Or some combination of these? What is most cost-effective approach?
- What is the most effective home protection strategy? A good alarm system, a large dog, a gun, or some combination of these? Can we prospectively replicate earlier evidence that suggests that having a gun in the home leads to an increase risk of death (for the gun owner) by suicide or homicide?
- Can we implement sensitive ED screening tools that flag patients at high risk for gun violence like we attempt to do for suicidal tendencies and domestic violence?
These questions would be better informed by multiple prospectively studied interventions than by minimally informed stabs in the dark. Shouldn't we be able to pursue randomized or comparative effectiveness trials in the realm of firearm violence? Why are we muzzling science on a critical matter of public health?
Dr. Arthur Kellermann, one of the researchers whose work started the whole funding dustup, addressed this state of affairs in a recent essay: “Health researchers are ethically bound to conduct, analyze, and report studies as objectively as possible, and communicate the findings in a transparent manner. Policy makers, health care practitioners, and the public have the final decision regarding whether they will accept, much less act on, those data. Criticizing research is fair game; suppressing research by targeting its sources of funding is not.” (JAMA 2013;309:549.)
If silencing evidence-based medicine on a matter of political controversy bothers you as it does me, there are some steps you can take. Here are five suggestions.
- Let your elected representatives know what you think.
- Email, call, or write to private foundations to let them know that they can make a difference. The California Wellness Foundation (www.calwellness.org) is one of only a handful of private foundations currently supporting research into gun violence prevention, and it has already spent more than $120 million on studies of the “ecosystem attributes” that contribute to such violence.
- Learn more about the existing centers of academic excellence in this field and consider supporting them however you can. You can start with the Center for Gun Policy and Research at Johns Hopkins (http://bit.ly/YLN8tv), the Violence Prevention Research Program at UC Davis (http://bit.ly/XpY0At), and the Harvard Injury Research Control Center (http://hvrd.me/12XfJ6a).
- Get involved with professional organizations on this topic. National American College of Emergency Physicians has a trauma and injury prevention section, and a number of state chapters (including my home chapter in California) have active committees on this issue. ACEP should follow the example of the American Academy of Pediatrics, and take leadership position on this topic.
- Make use of the following links. Thanks to Jay Schuur, MD, MHS, for posting these in his letter in EMN. (2013;35:28; http://bit.ly/YHXk7u.)
- Write to the members of the ACEP Board of Directors at http://www.acep.org/board/.
- Contact your ACEP State Chapter at http://www.acep.org/chapters/.
- Email the American Academy of Emergency Medicine's Board of Directors at http://bit.ly/WrRU3Q.
- Write to the Society for Academic Emergency Medicine at http://www.saem.org/contact.
- Contact the Emergency Medicine Residents' Association at http://bit.ly/EMRAcontact.
- Email the Emergency Nurses Association at email@example.com.
- Reach the Society of Emergency Medicine Physician Assistants at http://bit.ly/SEMPAcontact.
Now, maybe, just maybe, people and politicians are willing to listen. A fantastic place to start is with lifting the moratorium on studying the disease process.
Since writing this perspective, President Obama issued an executive order directing the CDC to engage in gun violence prevention research. This is welcome news indeed, but the long-term implications of this order are unclear. Without congressional action, research funding remains very much at the mercy of the political climate. Please make your voice heard.
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‘Certainty’ about Gun Violence
Read more on this topic from Dr. Ballard in EMN's Breaking News blog at http://bit.ly/EMNBreakingNews.