Standing AFFIRM: Putting the ‘Public’ in Public Health : Emergency Medicine News

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Standing AFFIRM

Standing AFFIRM

Putting the ‘Public’ in Public Health

Barsotti, Christopher MD

Emergency Medicine News 44(3):p 24, March 2022. | DOI: 10.1097/01.EEM.0000824180.19960.18
    public health, gun violence, violence prevention

    Americans come together in grief over each gun-related tragedy and senseless loss of life. We share astonishment that those closest to the perpetrator didn't recognize warning signs and that appropriate precautions weren't taken when violent risk factors are identified among unsafe people with access to guns.

    We are all frustrated by the lack of consensus on strategies to stop these tragedies from happening and disempowered by the reality that the only way any of us as individuals can help prevent firearm injuries is to participate in a rancorous political advocacy debate focused on the control of a consumer device.

    As emergency physicians whose practice is based on evidence and whose profession focuses on health outcomes, we must admit that our society's current approach to firearm injury prevention—political advocacy for legal control of a consumer device—has not yielded results.

    The number and frequency of school shootings—indeed, firearm injuries and deaths overall—only continue to rise. It's high time for a new approach that treats firearm injury for what it is: a health problem in need of health solutions.

    Unmet Health Needs

    The first step in establishing a health approach is to recognize that firearm injuries happen as a result of gun misuse, and this allows us to distinguish device safety from the health factors that determine human safety. Firearm safety training teaches us how to use the device safely for the purpose it is intended, whether for sport, hunting, or defense.

    The ultimate use of the device, however, is determined by the handler's mental, physical, and social health. The inappropriate use of the device to inflict harm—gun misuse—occurs when an individual has unmet health needs: Hurt people hurt themselves and others. True firearm safety requires device education with health education. The latter has been largely missing from firearm safety training to date.

    The second step is to recognize that the health approach requires the engagement of expert communities, which, in this case, necessarily means the U.S. population that chooses to exercise its Second Amendment constitutional right. Hundreds of millions of guns are privately owned by tens of millions of gun owners, including more than a third of emergency physicians and more than 40 percent of trauma surgeons. This community has been largely missing from firearm-related public health education so far.

    We must unify the traditions and knowledge of responsible firearm stewardship that have long existed within the firearm community with the expertise and risk reduction methods that exist within the health professions. We need to bring interdisciplinary professionals, health systems, and the populations we serve together to understand the problem as it exists in our unique communities and recognize the many resources we already have to address the health factors that contribute to or protect from gun misuse.

    Injury Prevention

    The line between safe and unsafe gun ownership is dynamic, and we know numerous health factors contribute to harmful behaviors. Many of these may be identified (up to 80 percent of perpetrators of targeted violence, for example, message their intent through leaks or threats) and then modified through health interventions. Equally important, we know many protective factors can be enhanced by clinicians, families, and communities. Our goal is to prevent injury, which means caring for and supporting people at risk of harming themselves and others, helping their families, and strengthening their communities.

    Fortunately, all of these things are within our immediate reach. The public health approach is a reliable tool for harm reduction and injury prevention and will decrease the incidence and prevalence of firearm-related injuries. The public health approach has four steps: define the problem; identify risk v. protective factors; test and evaluate intervention strategies; and ensure widespread adoption of effective strategies.

    Policy is commonly how we scale effective interventions (the last step), yet it is what we as a society focus on at the expense of fully fleshing out the first three steps and estranges the essential population with the device that has the ability, expertise, traditions, and desire to participate.

    Preventing firearm injuries and death is a priority concern for all Americans. It's time to practice what we preach in public health and enable everyone to be part of the solution.

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    Dr. Barsottiis the program director of AFFIRM at the Aspen Institute, a program dedicated to reducing firearm injuries in the United States through health-based, nonpartisan approaches. He is also a community practice emergency physician at Berkshire Medical Center in Pittsfield, MA, and a certified 4-H youth rifle safety instructor. Read his past columns at, find more information about AFFIRM at, and follow the foundation on Twitter@ResearchAffirm.

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