We are surgeons who have committed our personal and professional lives to reducing needless suffering from injury. As leaders in the American College of Surgeons Committee on Trauma (ACS COT), we have put our hearts and souls into reducing firearm violence, yet we continue to experience the senseless tragedy of mass shooting events and the daily impact of violence on our patients and our communities. Two of us (DK, RMS) personally cared for innocent victims in 2 of the largest mass shootings in modern American history: the Las Vegas, NV and Sutherland Springs, TX tragedies, which, within a little more than a month, left 84 dead and 871 injured.
We seek to provide a constructive path forward to reducing violent injury and death based on an effective and durable public health approach. Moving forward requires a new and inclusive narrative that resonates with a large percentage of Americans. We do not come to this opinion based on our personal beliefs or political affiliations. We come to this recommendation after decades of advocacy and 5 years of collective effort, inclusive dialogue, and research regarding firearm-related injury.
BRIEF SUMMARY OF THE FACTUAL DATA: BURDEN OF DEATH BY INTENT AND FIREARM MECHANISM Because the facts are often debated, we provide a summary of data regarding violent death in the US. In 2016, the latest year available from Centers for Disease Control and Prevention, there were 63,979 intentional injury deaths: an average of 175 deaths every day .1 Fig. 1 ).1
Figure 1.:
Injury-related death rate trends in the 21st century demonstrate an increase in intentional violent deaths as compared with a substantial decrease in unintentional traffic deaths. The increase in intentional death is driven by an increase in intentional self harm from both firearms and nonfirearm mechanisms and increases in firearm assault deaths.
1 OVERCOMING POLITICAL POLARIZATION AND CONFIRMATION BIAS Historically, the ACS COT and others have advocated for effective prevention; however, past efforts universally became mired in political debates around personal liberty and second amendment rights.
A majority in the US adhere to 1 of 2 contrasting narratives about firearm ownership. The first narrative is that firearms are beneficial, necessary, and a protected right. From this group's vantage point, firearms are emblematic of freedom. The strongest adherents link very tightly to this view, so that the term gun control synonymously translates into freedom control . The second dominant view is that firearms are harmful, generally unnecessary in civil life, and decrease personal liberty because of increased risk of harm. From this group's perspective, firearms are emblematic of violence. Strong adherents to this narrative tightly associate guns with violence; for them, gun control synonymously translates into violence control .
When faced with a perceived stress or crisis, those who view firearms as important for personal freedom push for greater availability and tend to purchase more firearms. Those of the second view push for increased firearm restriction, and generally protest the violence. Both sides appear convinced they are absolutely correct, and both react to each other by reinforcing their own position, while simultaneously villainizing the other. In his book, Choosing Civility: The Twenty-five Rules of Considerate Conduct , PM Forni states, “There are at least two ways of showing disrespect for others on account of what they think. One is by telling them that their opinions are crazy, stupid, worthless, and the like. The other is by assuming that what we think must be what they think also.”2
Worse than ineffective, incivility, and its language of disrespect, is a precursor to psychological and physical violence. Proclaiming another human being as stupid and worthless is the first step to dehumanization—a common tool the physically violent use to justify their actions. For those prone to violence, the belief that the other person must think only the way they think becomes a justification for forced interpersonal control—psychological and then physical.
Sadly, rather than effectively addressing violence, the 2 conflicting narratives are a war of words that, at least to us, foreshadows violence. The time is now to end this nonconstructive debate. To do so requires crafting a common, inclusive narrative that resonates with most Americans.
THE AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA PUBLIC HEALTH APPROACH Reducing violence-related intentional injury requires a multifaceted, integrated public health approach.3-9
Over the past 4 years, we have evaluated and published our firearm injury prevention strategies, surveys of surgeons' views, and implementation strategies for a national trauma action plan.3-5 4,7 1 6 4,7
THE 3 MOST IMPORTANT LESSONS LEARNED
Violent intentional injury is the most poorly addressed public health problem in America . Although complex, there are many readily correctable factors. The resources to address the problem should match the burden of disease .
Those on the 2 polar sides of the discussion can and must work together . Both groups abhor the needless death and suffering, and both agree the focus must be on reducing deaths and injuries.
Both sides agree that a common goal should be to make firearm ownership as safe as reasonably possible . This approach enables partnership opportunities and the power of technology and innovation to reduce injury death and disability.
CONCLUSIONS Effective violence-related injury prevention requires engagement, responsibility, and partnership across disciplines, geographic regions, and philosophic differences. A commitment to the values of civility, professionalism, humility, and mutual respect is required. The time is now for political differences to be set aside, for polarizing and incendiary language to be avoided, and for our energies to be devoted to thoughtful policy development and specific actions in the context of a public health model.
We all own the epidemic of violence in the US, and courageous leadership is needed. Firearm owners, those who do not own firearms, advocacy groups across the spectrum, the faith community, our legislators, industry, the science and technology community, professional societies, activists, organizers, and the general public must commit to working together . For this we need a new and common narrative that is inclusive of the broad conflicting narratives in the US.
We propose the following as a starting point: Firearm ownership is a liberty protected by the US Constitution. Violence toward ourselves and others is a major cause of unnecessary death and suffering in America1 10,11 9-11 6
If we come together, focusing our efforts on reducing violence while making firearm ownership as safe as reasonably possible, we can and we will save thousands of American lives every year.
AUTHOR CONTRIBUTIONS Study conception and design: Stewart, Kuhls, Rotondo, Bulger
Acquisition of data: Stewart, Kuhls, Bulger
Analysis and interpretation of data: Stewart, Kuhls, Rotondo, Bulger
Drafting of manuscript: Stewart
Critical revision: Stewart, Kuhls, Rotondo, Bulger
REFERENCES 1. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death. 1999-2016 on CDC WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Available at:
http://wonder.cdc.gov/ucd-icd10.html , 18, 2, 2018.
2. Forni PM. Choosing Civility: The Twenty-five Rules of Considerate Conduct. New York: St Martin's Press; 2002. Kindle Edition; 77.
3. Jenkins DH, Winchell RJ, Coimbra R, et al. Position statement of the American College of Surgeons Committee on Trauma on the National Academies of Sciences, Engineering and Medicine Report: A national trauma care system: integrating military and civilian trauma systems to achieve zero preventable deaths after injury. J Trauma Acute Care Surg. 2016;81:819-823.
4. Kuhls DA, Campbell BT, Burke PA, et al. Survey of American College of Surgeons Committee on Trauma members on firearm injury: consensus and opportunities. J Trauma Acute Care Surg. 2016;82:877-886.
5. Stewart RM, Kuhls DA. Firearm injury prevention: a consensus approach to reducing preventable deaths. J Trauma Acute Care Surg. 2016;80:850-852.
6. Dicker RA, Gaines BA, Bonne S, et al. Violence intervention programs: A primer for developing a comprehensive program for trauma centers. Bull Am Coll Surg. 2017;102:30-36.
7. Puls MW, Kuhls DA, Campbell BT, et al. Survey of the American College of Surgeons Board of Governors on firearm injury prevention: consensus and opportunities. Bull Am Coll Surg. 2017;102:30-36.
8. Bleedingcontrol.org. Available at:
www.bleedingcontrol.org , 11, 1, 2017.
9. Bass BL, Neumayer LA, Stewart RM, Hoyt DB. Violence prevention: an update. Available at:
https://www.facs.org/quality-programs/trauma/violence-prevention , 27, 3, 2018.
11. Giffords Law Center. Guns and suicide. Available at:
https://giffords.org/issue/guns-and-suicide/ , 4, 4, 2018.
