In 2019, the American College of Surgeons (ACS) hosted the inaugural Medical Summit on Firearm Injury Prevention. The Summit convened representatives from 44 major medical, public health, and injury prevention professional organizations with a goal to develop consensus on collaborative opportunities to address the growing problem of firearm-related injury and death in the US.
The attendees and organizers of the inaugural Medical Summit described a multifaceted, comprehensive public health and medical approach to reducing firearm injury, death, and disability. Haddon’s matrices were created for the major intents of firearm-related injury (suicide, interpersonal violence, and unintentional injury) with a detailed description of injury prevention initiatives in each area. In addition, 47 organizations subsequently agreed to 9 consensus statements focused on defining this public health approach (
Table 1). The statements highlighted the importance of federal funding for research, the importance of engaging firearm owners and communities at risk for firearm-related injury in developing interventions, the role of healthcare professionals in screening for risk factors and counseling patients for injury prevention, and the role of hospitals and healthcare systems in addressing the social determinants of health in communities disproportionately impacted by violence. The final consensus statement was a commitment from all participating organizations to continue to work together to implement these strategies.
Table 1. -
Consensus-Based Approach to the Issue of Firearm Injury Prevention Supported by 47 Organizations During the 2019 Medical Summit on Firearm Injury Prevention
1. Firearm death and injury in the US is a public health crisis.
2. A comprehensive public health and healthcare approach is required to reduce death and disability from firearm injury.
3. Research is needed to better understand the root causes of violence, identify people at risk, and determine the most effective strategies for firearm injury prevention.
4. Federal and philanthropic research funding must be provided to match the burden of disease.
5. Engaging firearm owners and populations at risk is critical in developing programs and policies for firearm injury prevention.
6. Healthcare providers should be encouraged to counsel patients and families about firearm safety and secure firearm storage. Educational and research efforts are needed to support appropriate culturally competent messaging.
7. Screening for the risk of depression, suicide, intimate partner violence, and interpersonal violence should be conducted across all healthcare settings and in certain high-risk populations (such as those with dementia). Comprehensive resources and interventions are needed to support patients and families identified as high risk for firearm injury and who have access to a firearm.
8. Hospitals and healthcare systems must genuinely engage the community in addressing the social determinants of disease, which contribute to structural violence in underserved communities.
9. Our professional organizations commit to working together and continuing to meet to ensure these statements lead to constructive actions that improve the health and well-being of our fellow Americans.
Despite this focused commitment, firearm-related injury remains one of the most important public health problems of modern time. Yet since the 2019 Summit, levels of violence have continued to increase in the US. According to data from the US Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) database, the preliminary 2021 data demonstrate that there were 48,830 deaths from firearm injury of which 26,320 (53.9%) were suicides, 20,948 (42.9%) homicide, 635 (1.3%) legal intervention, 537 (1.1%) unintentional discharge, and 390 (0.8%) unknown intent.
This equates to 134 deaths per day. These data reflect a 23% increase in firearm-related injury overall since 2019 and a 46% increase in firearm-related homicides. This is consistent with several recent studies documenting the increase in firearm-related violence, both fatal and nonfatal injuries, during the course of the COVID-19 pandemic. The rate of firearm sales in the US has also escalated during this time period. A recent report evaluating national data from the first year of the pandemic noted a 28.4% increase in firearm-related death and a 34.3% increase in nonfatal firearm injury. 2 Firearm-related injury disproportionately impacts children, adolescents, and young men of color. An analysis of 2020 CDC data noted that firearm-related injury has now eclipsed motor vehicle fatality as the leading cause of death in the US for those age 1 to 19 years. 3 The rates of both firearm-related suicide and homicide among young people increased during the pandemic. 4 Black men ages 15 to 34 years were more than 20 times more likely to die by firearm homicide compared with their White counterparts. 5 After an initial dip during the early phases of the pandemic, mass shootings have continued to increase with several high-profile mass killings in 2022 (eg Buffalo, Uvalde, and Highland Park). 6 7
In the context of this ongoing public health crisis, leaders of the American College of Surgeons, American College of Physicians, American College of Emergency Physicians, American Academy of Pediatrics, and the Council of Medical Specialty Societies agreed to cohost a second Medical Summit on Firearm Injury Prevention in 2022 to renew collective, action-oriented efforts to address this ongoing public health crisis. A multidisciplinary planning committee with representation from these organizations was convened and invitations extended to 67 organizations, including all those engaged in the 2019 summit. The goal was to be maximally inclusive and maintain a nonpartisan public health and medical approach.
The objectives for the 2022 Summit were to: (1) use a consensus-based, nonpartisan approach to identify recommendations for executive action and/or legislation at the municipal, state, and federal level that would decrease firearm-related injury and (2) identify key elements of the most effective violence-reduction programs for implementation by physician practices/clinics/hospitals/health systems, in partnership with their communities, to lower the risk of violence for marginalized communities disproportionately impacted by violence.
The conference was hosted at the headquarters of the American College of Surgeons in Chicago, September 10 to 11, 2022, with an online virtual component to maximize participation. Representatives from 46 organizations (
Supplemental Digital Content 1, ) attended and participated in the discussions. The conference included 3 plenary sessions with presentations by leading speakers in the field along with moderated breakout discussions ( https://links.lww.com/JACS/A220 Supplemental Digital Content 2, ). The 3 main areas of focus were: public policy initiatives, addressing community violence, and effective healthcare-centered communication on firearm injury prevention. These proceedings summarize the presentations submitted by the speakers and identify next steps for firearm injury prevention activities for the coalition of organizations based on participant discussion. https://links.lww.com/JACS/A220 SESSION 1: PUBLIC POLICY INITIATIVES: A CRITICAL OPPORTUNITY TO CHANGE FIREARM POLICY AND SAVE LIVES
Role of advocacy and policy change
This presentation reviewed the role of advocacy and policy changes in reducing gun violence, current trends in firearm policy, and future directions for evidence-based firearm policy. The discussion about advocacy and policy change to prevent firearm-related violence starts with recognition that data show that certain gun laws do reduce firearm injury. For instance, strong data demonstrate that Connecticut, a state with a purchaser licensing law (also known as Permit-to-Purchase), had a significant reduction in rate of firearm homicide (28%) and firearm suicide (33%) during the 22-year period since the law was enacted. By comparison, the repeal of Missouri’s purchaser licensing law was associated with an increase in rate of firearm homicide and firearm suicide (47% and 23%), respectively.
Advocacy has the potential to impact upstream factors that include law and institutional practices that can prevent injury.
It is increasingly recognized that public health practitioners, including healthcare workers, play a critical role in advocating for policy changes, including statutory changes that have contributed to many important public health achievements. 11 Healthcare professionals on the front lines of caring for people injured or killed have a unique voice in advocating for policy solutions and the change needed to prevent firearm-related violence. In the past 2 years, firearm sales have increased along with the number of new firearm owners in the US. 12 Yet, recent polling suggests there are significant levels of support for strong firearm violence prevention policies, suggesting there is room for effective policy solutions to gun violence that appeal across the population. 13 14
States take divergent approaches to firearm policy. In the past several years some states have eliminated requirements for a permit before engaging in concealed carry of a firearm.
In contrast, other states have continued to advance strong firearm violence prevention policies with comprehensive background check systems, minimum age requirements, and bans on high-capacity magazines and assault weapons. 15 After the shootings in Buffalo, NY and Uvalde, TX in May 2022, a number of states adopted new packages of firearm injury prevention laws including Delaware, New Jersey, and New York. States with discretionary concealed carry licensing (“may” issue states) were forced to respond to the Supreme Court’s ruling in 16 New York State Rifle and Pistol Association v. Bruen that held that the state of New York’s proper-cause requirement for obtaining a license to carry a concealed firearm was unconstitutional. This Supreme Court ruling will impact other states similar to New York, with the public health impact yet to be determined. 17
At the federal level, there were several recent changes that have strengthened firearm policy. In April, the Biden Administration announced the enactment of a final rule regulating ghost guns, which are a growing public health threat. “Ghost” guns are privately made firearms that can be assembled from kits (or 3-dimensional printed) and lack a serial number, making them untraceable. Among other things, the new rule bans the sale of ghost gun kits, which enabled an individual with no specialized equipment to assemble a firearm lacking a serial number in less than an hour.
In June 2022, in the wake of the mass shootings in Buffalo and Uvalde, the Bipartisan Safer Communities Act was passed and signed into law. This legislation provides significant federal funding to implement state crisis intervention initiatives, including extreme risk protection order programs; establishes a federal statutory framework to prohibit straw purchasing of firearms; extends federal firearms-related restrictions to individuals who are convicted of a misdemeanor crime of domestic violence and are in a current or recent former dating relationship with the victim; and provides new investments in community violence intervention and prevention programs. 18 19
Although some progress has been made, firearm-related violence remains a significant public health burden that could be reduced with additional policies at all levels of government. A coordinated national approach is critical.
Policy changes with the potential to reduce firearm-related injury based on an evidence-based approach include expansion of the background check system, including firearm purchaser licensing that requires prospective gun purchasers to obtain a license before buying a gun 20 ; firearm risk reduction laws, such as Domestic Violence Protection Orders 21 and Extreme Risk Protection Orders 22 ; funding for Homicide Review Commissions 23 and community violence intervention programs 24 ; and limitations on high-capacity magazines. 25 26 Evidence on the efficacy of firearm legislation
This presentation presented scientific evidence on the effects of existing firearm legislation to prevent firearm-related harm and identified areas for future research. Several resources on current firearm laws are listed in
Table 2. A compendium of firearm laws can also be created by using sources such as Westlaw ( ), LexisNexis ( https://legal.thomsonreuters.com/en/westlaw ), or HeinOnline ( https://www.lexisnexis.com/en-us/gateway.page ). https://home.heinonline.org/
Table 2. -
Examples of Sources for Review of Firearm Legislation
As part of their Gun Policy in America initiative (
), the RAND Corporation conducted a comprehensive systematic review of evidence on the effects of firearm policies. The authors modeled their review using the 5-step methodology based on the Royal Society of Medicine’s systematic review process and augmented with guidelines from the Campbell Collaboration for reviews of social and policy interventions ( https://www.rand.org/research/gun-policy.html ). This effort collated complete information on all state firearm laws from January 1979 through June 2022 in 20 broad categories as a public database. From this list, 18 specific firearm policies were selected for review of the evidence on their effects on 8 specific outcomes using literature published from January 1995 through October 2020 ( https://www.rand.org/research/gun-policy/methodology.html Tables 3 and 4).
Table 3. -
List of Firearm Policies Included in the RAND Critical Synthesis of Research Evidence
Regulating who may legally own, purchase, or possess firearms
1. Minimum age requirements
2. Prohibitions associated with mental illness
3. Prohibitions associated with domestic violence
4. Surrender of firearms by prohibited possessors
5. Extreme risk protection orders
Regulating firearm sales and transfers
6. Background checks
7. Licensing and permitting requirements
8. Waiting periods
9. Firearm safety training requirements
10. Lost or stolen firearm reporting requirements
11. Firearm sales reporting, recording, and registration requirements
12. Bans on the sale of assault weapons and high-capacity magazines
13. Bans on low-quality handguns
Regulating the legal use, storage, or carrying of firearms
14. Stand-your-ground laws
15. Child-access prevention laws
16. Concealed-carry laws
17. Gun-free zones
18. Laws allowing armed staff in kindergarten through grade 12 (K–12) schools
Table 4. -
Outcomes Included in the RAND Critical Synthesis of Research Evidence
2. Violent crime
3. Unintentional injury and death
4. Mass shootings
5. Officer-involved shootings
6. Defensive gun use
7. Hunting and recreation
8. Gun industry
The RAND research team found that few firearm policy–outcome pairs had been subjected to methodologically rigorous investigation. The investigators found supportive or moderate evidence that: (1) child access prevention or safe storage laws reduce self-inflicted fatal or nonfatal firearm injury (including unintentional and intentional self-injury) as well as firearm homicide among youth; (2) waiting periods reduce firearm suicide and total homicides; (3) background check requirements reduce firearm and total homicides; (4) prohibitions associated with domestic violence reduce total and firearm-related intimate partner homicides; (5) stand-your-ground laws increase firearm and total homicides; (6) shall-issue concealed-carry laws increase firearm and total homicides; and (7) more-restrictive minimum age of purchase laws reduce firearm suicide. The investigators also found limited evidence for the effect of several laws, some of which include: (1) licensing and permitting requirements reduce firearm and total suicides among adults; (2) minimum age requirements for possessing a firearm reduce firearm suicide among young people; (3) bans on high-capacity magazines reduce mass shootings and fatalities; (4) firearm-surrender laws, when paired with expansions of prohibited possessor classes, reduce total intimate partner homicides; (5) waiting periods reduce total suicides and firearm homicides; (6) prohibitions associated with domestic violence reduce total homicides; (7) stand-your-ground and shall-issue concealed carry laws increase violent crime; and (8) child access prevention or safe storage laws reduce unintentional firearm injury and death among adults. For many other policies, the investigators either found no studies examining the effect or they found the evidence to be inconclusive. This rigorous systematic review was limited, because it included only selective firearm policies and did not provide information on implementation, dissemination, or enforcement. As research on the progressive impact of firearm policies continues, future updated syntheses of evidence to inform policy will be imperative (
Table 5. -
Areas for Future Research on the Effects of Firearm Policies to Prevent Firearm-Related Harm
Future research area
1. Interrogating causal pathways and mediation analyses should play a critical role in policy evaluations, yet few published studies in the firearm policy literature have taken this approach
Understanding 27-30 how/why firearm policies affect (or do not affect) their intended outcome is critically important to inform the modification of existing policies and development of new policies.
2. For many firearm policy–outcome pairs, there is simply no evidence in the existing literature. Future research should devote particular attention to those pairs, including nonfatal firearm injury outcomes.
3. Firearm policies vary tremendously across different states. Even under the same broad gun law category (eg background check laws, child access prevention laws, concealed carry laws), state firearm policies vary in terms of their design and specifications.
As such, future research should disaggregate policies based on their specific features when appropriate to understand what specific design features may be more effective than others. 32
4. Methodologically, new quasi-experimental approaches should be used to re-examine firearm policy-outcomes that have already been studied, and to examine those that have not been studied. The past decade has seen a sea-change in difference-in-difference analytic approaches
and use of modern techniques such as generalized and augmented synthetic control methodologies 33 that could be used more frequently in firearm policy research. 34
5. A specific firearm policy may have notably different effects among different subgroups in the population.
Evaluation of such moderation (ie effect measure modification) of policy impact among different subgroups will be highly important to inform equitable and fair policies. 35
6. A specific firearm policy does not affect its intended outcomes in isolation. Inevitably, there are many other firearm policies and nonfirearm policies (eg social and economic policies) that may impact those outcomes.
The examination of interaction (ie synergy or antagonism) between firearm policies themselves and between those policies and nonfirearm policies should be an important area for future research. 36
Engaging firearm owners
All too often the community of firearm owners in the US are approached as part of the firearm injury problem, and less commonly as part of the solution.
Many healthcare organizations have called for using a public health approach to address the epidemic of firearm-related violence, and a key element of this approach is broad community engagement. 37 The degree of community engagement can make a critical difference in the efficacy of a public health and/or a healthcare program. Although Americans may disagree about the role of firearms in our society, a significant majority agree that action should be taken to eliminate firearm injury. Developing an inclusive strategy that engages a broad set of stakeholders, including firearm owners, while approaching the issue with equipoise and pragmatism, is more likely to lead to effective community engagement, coalition building, and more effective programs and legislation. 38-40
The ACS Committee on Trauma has pursued a broadly inclusive strategy that takes in all points of view to develop a consensus-based approach within a public health framework.
This strategy led to the development of a “common narrative” that acknowledges 41 both the constitutional right to keep and bear firearms and the critical and significant problem of intentional firearm violence in the US. This approach focuses on working together to fully understand and address the underlying root causes of violence, while simultaneously working to make firearm ownership as safe as possible (for both firearm owners and those who do not own a firearm). This inclusive and comprehensive approach has led to a range of strategies, such as promoting responsible and safe firearm ownership, implementing community and hospital-based violence intervention strategies, increasing high-quality firearm injury prevention research, enhancing access to mental healthcare, and engaging in bipartisan advocacy and policy change. This approach is supported by a very large proportion of US ACS members, as evidenced by a survey of the entire US ACS membership and detailed analysis of the subset of ACS members who keep firearms in their homes (42%). Three-quarters of firearm-owning surgeons have handguns in their home and keep firearms for self-defense/protection. 42 The results of this survey demonstrated a diversity of views, but, in general, ACS members, including those who own firearms, support most initiatives and policies related to firearm injury prevention (eg federal funding for firearm injury research, implementing proven injury prevention programs, preserving healthcare workers’ right to counsel patients about firearm safety, and enhancing and strengthening mandatory background checks). 43
At the outset of the COVID-19 pandemic there was a surge in firearm sales, predominantly handguns, likely motivated by concerns about civil unrest and personal safety.
Americans who buy firearms for personal protection may do so to help manage psychological threats that come from a belief that the world is a dangerous place and society may not keep them safe. 44 A recent survey of firearm owners in the US demonstrated that a significant majority (81%) did not view physicians as a trustworthy source of information about firearm safety. 45 To overcome this barrier, several public health scientists have developed innovative ways to create and study partnerships between health professionals and firearm retailers, instructors, and advocates, to implement measures to lower harm for individuals at increased risk of firearm injury. This model of collaboration using firearm owners as experts and as “trusted messengers” has been tried in several states and has been successful largely because firearm owners and the organizations to which they belong are particularly well-suited to delivering firearm and lethal means safety messages in a culturally and technically competent fashion. 46 37 , 47 , 48
One element of the ACS strategic action plan to address firearm violence was the creation of the Firearm Strategy Team (FAST) Workgroup in 2018. This workgroup was charged to develop effective and actionable strategies that, if implemented, could produce a significant and durable reduction in firearm injury while preserving constitutional freedoms. The membership of this workgroup included a geographically representative sample of surgical leaders who owned firearms. These members had expertise and insight in hunting, competitive shooting, self-defense, law enforcement, and/or had a history of military service.
The FAST Workgroup deliberately focused the discussion on work that could reduce the burden of firearm injury and preserve the ownership rights of law-abiding Americans. To be included as a recommendation, all 22 members of the group had to agree. Although not representing all firearm-owning surgeons, this group’s initial recommendations addressed ownership, registration, licensure, education and training, ownership responsibilities, mandatory reporting and risk mitigation, safety innovation and technology, research culture of violence, social isolation, and behavioral health in a meaningful way
( 49 Fig. 1). Figure 1.:
FAST Workgroup Recommendations. ACS, American College of Surgeons; COT, Committee on Trauma; FAST, Firearm Strategy Team; NFA, National Firearms Act; NRA, National Rifle Association.
There was consensus from the participating organizations at the 2022 Medical Summit that engaging firearm owners broadly was an important approach, consonant with both community engagement and garnering bipartisan support for public policy approaches to lessen the burden of firearm injury. Several groups expressed interest in repeating the ACS survey of firearm injury prevention within their own organization to better understand member attitudes and behaviors surrounding firearms and to better inform organizational efforts on this topic. There was also strong support for creating a multidisciplinary FAST Workgroup with participation of firearm-owning members from each of the medical organizations that participated in the medical summit. This group could identify and endorse pragmatic prevention approaches based on the best available evidence, and then take these measures to others in firearm-owning communities for endorsement and dissemination.
SESSION 2: ADDRESSING COMMUNITY VIOLENCE
Social determinants of violence
Addressing the social determinants of health was cited as an important public health intervention during the 2019 Firearm Injury Prevention Summit.
After that first summit, the ACS established a multidisciplinary working group called Improving Social Determinants to Attenuate Violence (ISAVE) to develop strategies for firearm injury prevention in this context. 1
The social determinants of health are the nonmedical factors that influence health. The World Health Organization defines social determinants of health as the conditions in which we are born, grow, live, work, and age and the wider set of forces and systems shaping the conditions of daily life.
They represent significant root causes of health inequity. Included in the specific factors that have a positive or negative impact on health, depending on the community and individual, are income, employment, education, food insecurity, housing, and social inclusion. 50
The broad impact on violence and other chronic disease states can be illustrated by starting with an original redlining map of a particular city and overlaying maps of structural factors such as power plants along with the incidence of firearm violence and homicide, obesity, childhood asthma, food deserts, early cardiopulmonary disease, early sequelae of poorly controlled diabetes, and low life expectancy.
This overlap, coupled with a high area deprivation index, demonstrates the impact of social and structural determinants of health at all stages in life and across communities. 51
Trauma centers and healthcare systems are essential in treating the downstream physical and psychosocial consequences of the social determinants of health. ISAVE’s charge was to outline strategies to move upstream, working in partnership with marginalized communities and municipalities, to address the root causes of violence. ISAVE identified 4 areas of opportunity to address social determinants of health: (1) develop and implement a Trauma Informed Care curriculum; (2) identify strategies for integration of psychosocial care into trauma care (such as hospital- and community-based violence intervention programs); (3) support investment by healthcare organizations in disenfranchised communities the organization serves; and (4) advocacy for support of the 3 strategies.
The Substance Abuse and Mental Health Services Administration has outlined the importance of a trauma-informed approach to the care of patients in general. This approach acknowledges that “trauma” includes both physical and psychosocial injury and requires an understanding that many injured by violence may have a life-long struggle with adverse childhood events,
previous trauma, living in unsafe environments, and toxic stress. Trauma Informed Care introduces an approach that acknowledges these life-long struggles and establishes a method that addresses implicit bias, creating an environment for our patients that promotes equity, sensitivity of broader needs, and empowerment. A curriculum has been developed that includes trauma-informed principles and segments that address specific community inequities along with the provider risk of secondary trauma. Pilots of the course began this past year in 14 trauma centers across the US in order to inform the development of a dedicated Trauma Informed Care chapter for the next edition of the Advanced Trauma Life Support Course. 53
The social care construct acknowledges that, alongside standard medical and surgical practice, the trauma center can serve an important role in addressing immediate and longer-term social and mental health needs. This construct has been developed to improve patient-reported outcome measures
by enhancing an individual’s life course after injury. An example would be hospital-based violence intervention programs (HVIPs) in which credible messengers, also referred to as lived experience experts, are incorporated into the trauma service as Violence Prevention Professionals. They develop long-term relationships with violently injured individuals and work to address unmet psychosocial and mental health needs long after discharge. 54 More than 40 programs now exist across the country. The Health Alliance for Violence Intervention (HAVI) 55-59 has developed Standards and Indicators for HVIPs to aid in maintaining the fidelity, best practices, and sustainability of these programs. Comprehensive care clinics and family justice centers are also models for addressing psychosocial care needs and may be implemented in conjunction with HVIPs. 60
Moving further upstream involves addressing socioeconomic inequity in communities plagued with violence. This includes closing the racial wealth gap as a key strategy in reducing health disparity.
Trauma centers and health systems can play a role by investing in communities in a number of ways: sourcing consumables such as cafeteria food from disenfranchised local proprietors, offering vocational training and job opportunities to local community members, and investing in housing and other forms of infrastructure. Leveraging opportunities through community needs assessment can springboard efforts. Institutions can make earnest commitments by joining organizations such as the Healthcare Anchor Network ( 61 ). https://healthcareanchor.network
These 3 ISAVE strategies are critical solutions requiring clear lines of stakeholder communication that ensure effective and inclusive advocacy. An example has been advocacy supporting bills at the state level that allow the Centers for Medicaid and Medicare Services to cover the fee for service of violence prevention professionals in HVIPs. Such legislation has been passed in 5 states to date.
Advocacy for incorporating best practice in trauma-informed care is another critical area that ISAVE endorses. 62
ISAVE strategies are focused on the trauma center’s role in addressing root causes of violence to improve long-term outcomes and positively alter the life course of injured patients. The strategies provide excellent opportunities in developing more comprehensive care for our patients and ultimately the communities we serve.
Perspectives from the health alliance for violence intervention
The HAVI underscored the urgency of addressing community violence, discussed HVIPs as a core evidence-informed community violence intervention (CVI) strategy, and highlighted the broad support that CVI methods have recently received.
The HAVI is working to heal cycles of systemic and interpersonal violence through the advancement of HVIPs. HVIPs are multidisciplinary programs that combine the efforts of medical staff with trusted community-based partners to provide safety planning, case management services, and trauma-informed care to violently injured people to reduce re-injury and promote comprehensive recovery. The HAVI currently supports more than 85 cities with high rates of violence in building community and hospital partnerships. 60 60
There is a growing body of research that demonstrates the importance of CVI strategies guiding further research that leverages dynamic systems modeling to capture the impact of violence intervention ecosystems.
A single intervention cannot reverse group- and structural-level patterns of violence, but a constellation of effective interventions and policy change can. Recently, a national consortium of researchers serving as The John Jay College Research Advisory Group conducted a meta-analysis of the existing academic literature on community violence intervention. The advisory panel offered recommendations focused on strategies to reduce violence by using health approaches, including the deployment of CVI models, such as HVIPs, working in concert to address community violence ( 63 ). https://johnjayrec.nyc/2020/11/09/av2020/
Scientific inquiry, successful CVI demonstration, contemporary social forces, and current events have coalesced to create national interest in HVIPs and broader community violence interventions. Community violence intervention is covered by national media, included in bipartisan legislation at the federal and state level, and supported by the public based on recent HAVI/Data for Progress polling.
Healthcare organizations can capitalize on this momentum and collaborate across sectors to end community violence. 64 Advancing community place-based violence prevention strategies:
the Cardiff Model
Urban communities have an opportunity to clearly define the scope and nature of violence prevention by breaking down the silos that exist within neighborhoods to make communities safer. It is essential to establish relationships that are grounded in trust and to promote collaboration across sectors. This multifaceted approach across sectors is predicated on developing a trusting partnership that results in healthcare systems, community organizations, public health departments, businesses, law enforcement, and other sectors of civil society. Such partnerships will position communities to identify and evaluate areas most in need of place-based intervention strategies through real-time geocoding of time, place, and day of violence occurrence.
The Cardiff Model
has demonstrated that partnering across sectors enables a comprehensive approach for tackling this public health burden through data sharing, collaboration, and effective implementation of solutions at the right time and the right place. 65 The Model originated in Cardiff, Wales, with leadership from Jonathan Shephard, MD, a maxillofacial surgeon. He recognized that by further informing when and where assault injuries occurred, there were opportunities for collaborating and developing place-based prevention strategies. He further recognized that law enforcement agencies do not know about all of the assault events that occur within their jurisdictions and that emergency department information from patients who present with assault injury (de-identified to name/address) would further inform the community about when/where assaults occur. 66 By combining the 2 sets of information (law enforcement and emergency department), the community can develop and evaluate place-based interventions to prevent assaults. 67 68
Evaluation of this model has demonstrated a 30% to 40% reduction in violence-related admission compared with other cities during the same time period (2003 to 2007).
69 , The CDC has developed a toolkit 70 to help provide guidance in operationalizing this model throughout the US. Currently, it is being implemented in West Allis and Milwaukee, Wisconsin, as well as Atlanta, Georgia. Implementation is also being explored in St Louis, Denver, and Philadelphia. 71 Community engagement programs: the Temple University experience
Recognizing the role that young people play in both violent perpetration and victimization, there are numerous examples of how healthcare systems have engaged the surrounding community. One example in Philadelphia is the Cradle to Grave Program. Launched in 2006 from Temple University’s level 1 Trauma Center, the program used both hospital and medical school resources to educate at-risk youth about the physical, emotional, and social consequences of gun violence. At the same time, young people are provided a glimpse into the clinical aspects of the public health crisis we face. By bringing at-risk young people into the hospital as students, the program seeks to reduce the likelihood that they will return as patients. Since inception, more than 14,000 young people have participated in this program. Program evaluation has demonstrated effectiveness in improving young people’s attitudes toward reducing violence.
This program highlights the important role that hospitals play, particularly those in urban settings, in tackling firearm-related violence. Hospital–community partnerships that extend to schools, juvenile justice organizations, and local stakeholders have a unique ability to educate community members about firearm-related injury, similar to population-based education about other public health crises. Ensuring that there is both community input and consistent community member participation in developing solutions is critical for community buy-in and trust. Proactive healthcare organization community violence prevention programs complement hospital-based violence prevention and intervention programs. To address the issue in a meaningful and lasting way, healthcare institutions must ultimately take on the work of dismantling the inequity and injustice that lie at the heart of the structural violence that impacts communities across the nation.
Project Inspire: a model for mentorship for at-risk youth, University of South Alabama, Mobile
Project Inspire is a hospital-led, comprehensive intervention that focuses on juveniles delinquent of firearm-related crimes. The strategy is to curb firearm-related violence and reduce recidivism by providing at-risk youth with education, exposure, opportunity, and mentorship. This program was created through partnerships between the level I Trauma Center at the University of South Alabama hospital, juvenile gun court, Mobile Mayor’s office, and law enforcement. The juvenile gun court selects participants for this program who are first-time gun offenders, ages 13 to 18 years. The program is spearheaded by the level I Trauma Center, using the hospital as a venue to engage participants and build trusting relationships.
The goal of Project Inspire is to impact the positive life trajectory of young people who participate. It is well established that adverse childhood experiences are directly related to negative outcomes such as aggressive behavior, alcohol and substance use, and posttraumatic stress disorder.
73 , Research has also shown that benevolent childhood experiences may counteract the effects of adverse childhood experiences. 74 75
The core curriculum consists of 5 pillars: trauma-informed training and confidence building, educational and professional development, financial literacy, entrepreneurship, and career-specific job shadowing and mentorship. The program is structured to run during a semester in concert with the public school system calendar schedule. Participants shadow healthcare professionals in several departments within the trauma center and participate on rounds in the trauma ICU. Participants are trained and verified in Basic Life Support and Stop the Bleed. Additionally, they engage in community service projects, develop lived experiences, build resumes, and prepare for job interviews. A significant portion of their time is spent together as a cohort and with their mentors to create a “family environment.” Such comprehensive experience develops relationships that extend far beyond the formal part of the course.
Building a regional coalition, University of Washington, Harborview Medical Center
Firearm-related violence disproportionately impacts communities of color, especially young men and those who are socioeconomically vulnerable.
Interpersonal violence is often concentrated in certain areas within communities, and this adversely affects the health and well-being of the those injured, families, and communities at large. It is vital that those living in the communities most impacted by firearm violence be engaged as partners in the development and implementation of solutions that impact their neighborhoods. 76-78
Successful hospital-based and hospital-linked violence intervention programs are deeply rooted in the communities these programs serve. These programs offer a comprehensive approach to treating survivors of violence by attempting to address the underlying risk factors for violent injury in a culturally competent fashion. One way to further sustain violence prevention work that cuts across sectors and leverages the talent within communities is to create “Regional Coalitions” within communities. Such coalitions enable a more unified approach to violence prevention by linking existing community organizations with trauma centers. Success will require us to work together and shatter the siloed approach that often exists.
An example of this type of coalition, the Regional Peacekeepers Collective in King County, Washington, launched in 2021. This collective brings 6 community organizations that work with high-risk youth in King County together with the only level I Trauma Center in the area. The goal of the collective is to “prevent and eliminate youth gun violence by ensuring sustainable conditions that allow young people to live and be healthy, happy, hopeful, and thriving.” This collective works collaboratively to: (1) prevent violence from occurring in the first place by engaging with high-risk youth through credible messengers in the community and creating opportunity and alternatives to violence for these youth; (2) provide rigorous intervention for survivors of firearm violence to improve outcomes after injury and to address underlying root causes that contributed to the violence with the ultimate goal of keeping these youth alive, safe, and ideally thriving; (3) providing secondary prevention services for younger siblings of youth injured or killed by gun violence; and (4) provide follow-up care and support for family restoration and community healing. Banding together as a regional collective has built fellowship across healthcare and community organizations; increased the capacity, skills and impact of those doing the work; and forged a deeper commitment to the surrounding region.
There are a number of challenges that exist in successfully executing these types of regional coalitions. Perhaps the most obvious are barriers in trying to operationalize and coordinate efforts across numerous entities that often have their own goals and objectives. These issues may ease over time as coalition relationships are built and trust is established. The other challenge is in consistent funding for violence intervention and prevention efforts. The collaborative approach may be more attractive to funding sources through demonstration of effective resource use and results.
Role of healthcare professionals and academic medical centers
All healthcare professionals have a role in firearm injury prevention across their main missions of patient care, education of future healthcare workers, research, and community engagement.
All clinicians who care for patients have the opportunity to identify those at risk of firearm injury and provide counseling to mitigate these risks. These clinical opportunities include, but are not limited to, secure firearm storage, lethal means safety counseling, and family support in the implementation of extreme risk protection programs (that temporarily remove firearms from the home of those at risk for suicide or domestic violence). Health professionals should incorporate firearm injury prevention into the training of the next generation of healthcare professionals. 79 Finally, healthcare professionals should advocate for policies and practices that reduce firearm injury and death. Academic medical centers can support a framework for healthcare professionals and their organization at large to engage in firearm injury prevention advocacy and advance research to define best practices for interventions and their implementation. 72 80 , 81 Investing in at-risk communities
In urban cities across the US, predictably and disproportionately, low educational attainment, low income, low health status, and higher rate of homicide and violent firearm injury occur in Black and brown neighborhoods. This is largely accepted as the status quo and often not questioned or explored to better understand why the root cause of these social issues impacting neighborhoods exist. These neighborhoods were created by policy-driven practices established in the 1930s that were intended to rebuild America after the economic crisis that followed the Great Depression of 1929. Some Americans were provided opportunities to build wealth, explicitly through home ownership, which remains one of the most common pathways to building generational wealth in America. Policies incentivized developers to build houses by subsidizing them with the caveat that they agreed not to sell or rent them to Black people. Maps of cities that were created divided communities and neighborhoods according to property value. They were color coded into blue, green, yellow, and red labels ranging from “best” (blue) to “hazardous” (red). The majority of Black people and immigrants lived in red areas and were unable to participate in the wealth- building pathway. They could not access financial services or get mortgages because their communities were deemed to be a risk. Those communities and residents were unable to reach their full potential to build thriving, robust, and sustainable local economies and attain the health and well-being that financial security creates for families.
The impact of redlining has perpetuated itself for decades.
In 2022, predictably, redlining maps demographically matched outcomes, because it relates to the impact of COVID-19, climate and environmental change, poor health and low income, and the distribution of firearm injury. Traditional interventions to address manifestations of redlining (such as food insecurity, public, or subsidized housing) primarily fill gaps of inequity vs eliminating the inequities. These subsidies are not designed to ensure that people and communities are empowered to gain independence, financial stability, and wealth creation. The lack of sustainability and capacity building inherent to the current design result in people always relying on these limited resources that can make them feel trapped (ie “cliff effect” or restrictions on allowable earned income). 82
Safety-net hospitals disproportionately treat residents from disinvested communities that have been historically redlined. These healthcare systems also receive a majority of violent firearm-related injuries and deaths. In 2018, Boston Medical Center (BMC) made a commitment to transform after asking the question “What is the role of a safety net hospital? Is it charity
exclusively in perpetuity or is it equity?” In recognizing that charity does not change life course trajectory and outcomes, BMC decided to transform with intentionality. The actions aimed to change life course trajectory, enabling patients and communities to change economic lanes in their communities to reach full potential and well-being, including building generational wealth. The effort extends beyond BMC through collaborations with multisector partners, including other healthcare systems. The 4 primary areas of focus are: (1) economic mobility and wealth-building ecosystems, (2) community revitalization, (3) health equity accelerator, and (4) community engagement. Economic mobility projects include local workforce development and financial education, intentionality in decision making for hiring, investment and procurement, and active participation in gap funding for small businesses. Community revitalization is focused on investing in community land trusts and affordable housing. The health equity accelerator project seeks to proactively identify equity gaps within our institution and close them expeditiously. This includes establishing standard procedures and removing subjective decision-making that data have shown to drive inequitable outcomes. Finally, BMC’s community engagement includes an equity partnership network that engages community groups to inform decision making in all pillars of this work. Leveraging the resources of healthcare systems
The healthcare industry and health systems, must take an active leadership role to reduce firearm deaths and injury. Healthcare leaders must prioritize firearm-related violence prevention through organizational commitments similar to other leading causes of death, such as heart disease and cancer. After many years of relative silence, healthcare systems have reached a turning point as more and more leaders are acting to stem the tide of violence. Collectively, healthcare system leaders have been troubled by the reality that firearms surpassed motor vehicle crashes as the leading cause of death
83 , among American children and adolescents. The horrific mass shootings in Uvalde, Texas, and Buffalo, New York, in May 2022 weighed heavily on our collective conscience—as well as members of Congress. 84
Healthcare professionals understand that “good health” goes beyond the delivery of acute healthcare services. Ensuring the health and well-being of communities means ensuring the ability for people to attain employment, being able to walk down the street without the fear of being shot, and living in neighborhoods where livelihood is not dependent on ZIP code. To tackle the social issues that marginalized communities face, we must define health more broadly than has traditionally been done.
Healthcare professionals can play a critical role to change the narrative around firearm-related violence and have demonstrated that it is possible to depolarize an issue traditionally viewed as a political controversy. Focusing on a public health and medical approach has shifted the narrative to prevention of firearm-related injury, death, and disability. This has transformed an issue once viewed as “radioactive” to one that is “attractive” for healthcare system engagement. Healthcare systems should capitalize on the power of dialogue and continue to re-frame and approach firearm-related violence as a public health issue. Healthcare systems can create a center or organized effort around firearm violence prevention through community partnerships. Many of these strategies are no different than what other corporations
across the US employ. 85
There are many positive examples of this approach. As part of an ongoing effort to advance firearm safety, education, violence prevention and research, numerous examples across the country have been mobilizing to incorporate a comprehensive approach to violence prevention through health system–community partnerships.
Health system leaders have the ability to focus on the science of injury prevention
and concentrate efforts to reduce the daily toll of firearm violence that is disproportionately impacting marginalized communities. It is critically important that our nation’s hospitals and health systems support and work collaboratively with leaders of violence intervention programs, who understand the root causes of firearm violence within their communities. This includes supporting local community-based organizations and violence intervention programs and prioritizing the development of systemwide hospital-based violence intervention grounded in trauma-informed care principles. 86
Another crucial area of support is advocating for well-supported and robust firearm injury prevention research, similar to how health systems have led the way in driving research funding for heart disease, cancer, and sepsis. This includes not only leveraging federal funding, but committing to bolster funding through health system resources, philanthropy, and other foundations that have supported firearm injury prevention research.
Healthcare organizations can also lead by implementing evidence-based strategies that reduce firearm injury at the system level. This includes empowering healthcare professionals with the knowledge and skills to counsel patients on firearm safety, while also facilitating partnerships with other trusted messengers. Other opportunities are to improve integration with health system community partners by providing gun locks, secure firearm storage recommendations, and other firearm injury prevention initiatives.
Several health systems have become actively engaged in firearm violence prevention efforts, appointing champions to lead efforts within their institutions and backing them with the necessary resources. By supporting these types of programs, health systems—and the business community in general—have the opportunity to demonstrate organizational commitment on this issue, empower staff and frontline healthcare workers to become agents of change, and emphasize to individuals, families, and organizations that healthcare systems are actively pursuing solutions to make communities safer.
SESSION 3: EFFECTIVE HEALTHCARE SECTOR COMMUNICATION ON FIREARM INJURY PREVENTION
The ability to communicate effectively with patients, colleagues, and communities is at the core of tackling the complex health problems. Although we recognize the importance of science as the foundation of evidence-based solutions, communicating the data and statistics alone is not enough. Effectively and accurately communicating the impact of firearm violence on our patients, families, and communities is critical to motivating action that reduced the burden of firearm-related injury and violence.
Elements of successful communication include the words, tone, nonverbal communication, and, perhaps most important, storytelling. This session was opened by Gita Pullapilly, a Hollywood writer and film director, who made the case for healthcare and injury prevention professionals being able to tap into their role as storytellers
and proposed a 7-step roadmap: (1) grab people’s attention from the start; (2) show them a new perspective; (3) do not judge or preach; (4) get personal; (5) endings matter; (6) leave them wanting more; and (7) prompt them to take action. 87
Using methods of message communication in a way that can be tailored to the audience (eg patients, policy makers, and community) facilitates a data-driven approach. Communication is an essential part to any aspect of the multifaceted strategy required to tackle any complex public health problem.
How the language of firearm injury influences injury prevention
Violence prevention interventions—whether 1-on-1 counseling or large-scale public campaigns—must consider the audience, messenger, and message. Firearm owners and families are heterogeneous, with varied demographics, reasons for firearm ownership, firearm handling and storage practices, cultural practices, and views about violence risk and prevention. Although firearm ownership is still highest among White heterosexual men, other demographic groups are also key audiences in the development and dissemination of firearm injury prevention interventions. These audiences may respond better to tailored messaging
and to relatable messengers. Communicating with broad audiences and demographic subsets at greater risk of injury are important strategies to effective injury prevention. Research on trusted messengers for firearm suicide prevention found that family members, law enforcement, and veterans/military service members were seen as the most credible messengers, with celebrities and physicians as the least credible 88 89 , (acknowledging variation among owner subgroups). 90
The framing of messages—the words used can also affect how the content is received. For example, in firearm suicide prevention, work has found that the term “means safety” is preferred to “means restriction,” because restriction suggests punitive or legal action.
Messaging to firearm owners may be better received if it appeals to an individual’s identity and core values as a firearm owner (eg culture of safety and responsibility) and uses neutral terms. 91 In 2022, a multidisciplinary group of experts suggested key terms to use (and avoid) for firearms, firearm suicide, and community violence. 92 Recommendations included: “secure firearm storage” (rather than “safe firearm storage”); “die by” rather than “commit” suicide; and “communities disproportionately affected by violence” rather than “inner cities” or “urban communities.” A full list of terminology is available online. 93 Additional research around communication, testing of varied messages, and those who might be the most effective messengers may help increase the likelihood of impactful interventions. 93 Counseling patients on firearm safety: closing the gap
Considering the role healthcare professionals have played in addressing numerous public health problems over the years, it is clear no single solution exists. Empowering clinicians with the knowledge and skills to discuss firearm safety has similar importance to clinician engagement in counseling for obesity, smoking, substance use, and preventive health. In 2015, 66% of 4,000 Americans surveyed indicated that it is at least sometimes appropriate for healthcare professionals to speak with their patients about firearm safety. Responses varied by firearm ownership status. Of those who believe a healthcare professional discussing firearm safety was at least sometimes appropriate, 54% were firearm owners.
Despite clinicians recognizing the importance of discussing firearm safety, when patients are asked whether any healthcare professional had ever discussed firearm safety, only 7.5% of adults who live in a home with a firearm had ever received safety advice from a clinician.
Among US veterans that percentage was only slightly higher at 9.2%. 95 96
To increase screening as a component of risk reduction from firearm-related injury, it is critical to close this practice gap. Several barriers to counseling exist, including lack of time in clinical encounters, discomfort on the part of those clinicians who are not knowledgeable about firearms, fear of offending or alienating patients, and inadequate resources to support counseling.
An additional barrier is lack of familiarity with legal protections for healthcare professionals. There are no state or federal statutes prohibiting healthcare professionals from asking about firearm access when the information is relevant to preserving the health of the patient or family. 97
Understanding existing resource and time constraints, there has been discussion about how best to screen patients. One option is to consider whether clinicians should use a risk-based screening tool for firearm safety or employ universal screening. Ongoing research regarding optimal counseling will provide guidance as to how best to proceed.
For clinicians who want to increase their knowledge and confidence, there are courses on effective counseling of patients on firearm safety, some of them providing free online continuing medical education. One example is the Bullet Points Project. Learners (n = 150) participated in a 45-minute video on firearm-related injury and death, and the proportion of learners who felt confident to counsel patients increased from 39% to 93%.
Similarly, after participating in a simulation-based educational program that trained psychiatry, internal medicine, and pediatric residents and fellows, only 4% responded at completion of being uncomfortable with counseling compared with 60% who initially stated discomfort with counseling patients on firearm safety. 98 99
Healthcare professionals can play an important role in screening and counseling patients on firearm safety and injury prevention. As trusted health professionals, we must gain cultural and technical competence and leverage that trust to reduce preventable firearm injury, death, and disability.
SUMMIT WORKGROUP REPORTS
Advocacy and health policy
The consensus of the Advocacy and Health Policy Workgroup at the second Summit was that the represented professional organizations should work to establish an ongoing coalition that would develop specific policy goals at both the state and federal level. This would leverage advocacy resources from multiple healthcare organizations to develop a clear strategy and remain consistent in message. A multidisciplinary firearm strategy team should be established with relevant stakeholders, including firearm owners, to advise the coalition on policy recommendations and the overarching communication strategy. In addition to promoting policy efforts that support firearm safety, there is a clear need to support policy implementation. For example, extreme risk protection orders are only effective if the public and those responsible for their activation are aware of these laws and how to apply them. A coordinated strategy at the state with the opportunity to engage the state chapters of the represented organizations will help move implementation of state laws that reduce firearm injury. The workgroup also recommended grass roots advocacy training for healthcare professionals specific to firearm injury prevention and establishing an online resource repository to support these efforts. Finally, this workgroup sees opportunities to expand the reach of firearm injury prevention activities through public–private partnerships, inclusive of businesses, healthcare organizations, and local governments.
Addressing community violence
The Community Violence Workgroup developed short-, medium-, and long-term goals for the widespread implementation of violence prevention programs (
Table 6. -
Areas of Focus and Next Steps for Community Violence Workgroup
1. Support expansion and funding of hospital violence intervention programs and community violence intervention programs including the Cardiff model
2. Community health needs assessments should integrate violence and ensure these programs reach high-risk community members
3. Hospitals and healthcare systems should form Community Advisory Councils to inform this work and develop true community partnerships in the creation of solutions.
4. Hospitals and healthcare systems should invest in the development of healthcare
5. Workforce training and pathways to employment for individuals from marginalized, disinvested communities.
6. Create a document/clearing house for how healthcare systems can value and demonstrate return on investment for community investment
1. Healthcare systems/trauma centers form collaborative violence prevention task forces
2. With cities, community groups, marginalized community members, law enforcement, and other relevant sectors to create city/regional collaborative efforts. These efforts could include epidemiology and surveillance programs, intervention strategies, and evaluation of impact.
3. Develop a catalogue of healthcare and hospital-based efforts to include a description of existing of hospital violence intervention programs and hospital-linked programs and examples of city/regional collaborative efforts.
4. Advocate for reimbursement of community health workers and violence intervention specialists.
5. Develop a roadmap and expectation of implementation of universal counseling across specialties for reducing the risk of violence, and firearm safety
6. Generate multimedia-based story-telling efforts of patient and healthcare worker experiences that helps illustrate violence prevention and intervention strategies
1. Community health needs assessments should incorporate economic strategies in closing the wealth gap, addressing upstream factors that lead to inequities
2. Hospitals and healthcare systems work with cities to invest in and promote safe, affordable housing and safe neighborhoods
The Communications Workgroup agreed that, to be effective, the coalition will need an overarching communication strategy and an online repository of information resources to support effective communication with patients and their families by all healthcare professionals. They recommended the dissemination of existing CDC toolkits, including the Cardiff Model, and the development of new toolkits to support counseling for firearm safety and the development of a blueprint for safer communities that provides resources for the development of violence intervention programs. A longer-term goal would be to integrate these principles into all aspects of medical education. This would involve the development of a curriculum that could be included in nursing, social work, medical schools, and postgraduate training programs. The workgroup also recommended finding more effective ways of storytelling, including collaboration with film and journalism schools and leveraging social media.
NEXT STEPS: COALITION BUILDING
To execute the vision outlined in this summit, the sponsoring organizations have agreed to establish the infrastructure for the
Healthcare Coalition for Firearm Injury Prevention. This coalition will be led initially by a steering committee including representatives from the American College of Physicians, the American College of Emergency Physicians, the American College of Surgeons, the American Academy of Pediatrics, and the Council for Medical Specialty Societies. Coalition membership will be open to all the organizations who have been engaged in the 2 firearm injury prevention summits as well as other professional organizations representing public health and/or healthcare professions. A communications committee will be established to develop an overarching communication strategy and establish a website to house firearm injury prevention resources.
Coalition workgroups will be established to focus on initiatives to advance firearm injury prevention using a public health approach and include:
Health Professional Education: This group will focus on strategies to incorporate firearm-related injury prevention into all aspects of health professional education. This education will include strategies for identifying patients at risk for firearm injury, counseling patients and families for secure firearm storage and lethal means safety, applying trauma-informed care, and understanding the social determinants of violence. Education products will be inclusive of physicians, nursing, behavioral health, social work, and prehospital professionals.
Advocacy and Policy Initiatives: This group will conduct an environmental scan of other relevant coalitions and advocacy activities to determine opportunities and need for additional efforts. This group will then seek to build consensus on policy issues at the state and federal level and develop strategies to advance these initiatives focused on responsible firearm ownership and addressing the root causes of violence. The talent of each organization will be leveraged to include governmental and legislative affairs experts who would serve as workgroup members, in addition to the clinicians.
Healthcare Professional Engagement for Firearm Safety: This group will explore strategies to engage members of the participating organizations, to include establishing a Multidisciplinary Firearm Strategy Team (M-FAST) inclusive of firearm owners for work on strategies to support safe responsible firearm ownership.
Community-Centered Approach for Violence Prevention: This group will seek to identify best practices for violence prevention and develop projects to support the engagement of hospitals and healthcare systems in programs that address violence in their local communities. They will execute strategies outlined by the community violence workgroup at the summit, and work with national violence prevention organizations such as HAVI. Parting thoughts
Firearm injury is the most neglected public health challenge of modern times. The firearm injury and violence epidemic has intensified during the COVID-19 pandemic. In cities and states across the US, tackling this problem requires a comprehensive public health approach to reduce injury and death. The healthcare and public health communities play vital roles in advocating for research funding for firearm violence prevention at a level that is proportional to the burden of disease, supporting firearm safety initiatives and addressing community violence. Establishing this coalition provides a venue to continue ongoing multidisciplinary collaboration and leverage the resources of the entire public health and healthcare community. Previous efforts to address motor vehicle crashes have demonstrated success through a multidisciplinary public health approach that has dramatically reduced motor vehicle fatalities in the US during the past 60 years. Working together, the 47 organizations represented at the Second Summit are confident to have a similar impact in firearm-related injury. This necessitates developing systems where individuals have a decreased risk of being injured, killed, or disabled by firearms. The opportunity is before us, and the time is now to address this critically important American public health problem.
Conceptualization: Sakran, Bornstein, Dicker, Campbell, Lois, Stewart, Kerby, Bulger
Data curation: Sakran, Bulger
Formal analysis: Sakran
Investigation: Sakran, Bulger
Project administration: Sakran, Bornstein, Campbell, Burstin, Sheehan, Lois, Kerby, Turner, Bulger
Supervision: Sakran, Bulger
Writing – original draft: Sakran, Bornstein, Dicker, Rivara, Campbell, Cunningham, Betz, Hargarten, Williams, Joshua, Nehra, Dreier, James, Sathya, Rowhani-Rahbar, Charles, Goldberg, Bulger
Writing – review & editing: Sakran, Bornstein, Dicker, Rivara, Betz, Hargarten, Joshua, Nehra, Burstin, Sheehan, Armstrong, Rowhani-Rahbar, Goldberg, Lois, Stewart, Kerby, Turner, Bulger
Resources: Burstin, Turner, Bulger
Funding acquisition: Bulger
The authors would like to thank the ACS staff, especially the Committee on Trauma, for their expertise and assistance throughout all aspects of the Summit and preparation of the manuscript.
1. Bulger E, Kuhls D, Campbell B, et al. Proceedings from the Medical Summit on Firearm Injury Prevention: A Public Health Approach to Reduce Death and Disability in the US. J Am Coll Surg 2019;229:415–430.
2. Centers for Disease Control and Prevention. CDC WONDER. About provisional mortality statistics, 2018 through last month. Available at:
. Accessed December 29, 2022.
3. Sun S, Cao W, Ge Y, et al. Analysis of firearm violence during the COVID-19 pandemic in the US. JAMA Netw Open 2022;5:e229393.
4. Goldstick JE, Cunningham RM, Carter PM. Carter current causes of death in children and adolescents in the United States. N Engl J Med 2022;386:1955–1956.
5. Thomas AC, Campbell BT, Subacius H, et al. National evaluation of the association between stay-at-home orders on mechanism of injury and trauma admission volume. Injury 2022;53:3655–3662.
6. Johns Hopkins Center for Gun Violence Solutions. A year in review: 2020 gun deaths in the U.S. 2022. Available at:
. Accessed December 29, 2022.
7. Richard Holt G, Benjamin GC, C Grossman D, et al. Gun violence and mass shootings as a public health priority in the United States: An expert panel discussion. Perm J 2022;26:6–19.
8. McCourt A, Crifasi C, Stuart EA, et al. Purchaser licensing, point-of-sale background check laws, and firearm homicide and suicide in 4 US states, 1985–2017. Am J Public Health 2020;110:1546–1552.
9. Webster D, Crifasi CK, Vernick JS. Effects of the repeal of Missouri’s handgun purchaser licensing law on homicides. J Urban Health 2014;91:293–302.
10. Crifasi CK, Meyers JS, Vernick JS, Webster DW. Effects of changes in permit-to-purchase handgun laws in Connecticut and Missouri on suicide rates. Prev Med 2015;79:43–49.
11. Simon C. Advocacy in public health: roles and challenges. Int J Epidemiol 2001;30:1226–1232.
12. Mello MM, Wood J, Burris S, et al. Critical opportunities for public health law: a call for action. Am J Public Health 2013;103:1979–1988.
13. NSSF (National Shooting Sports Foundation). NSSF retailer surveys indicate 5.4 million first-time gun buyers in 2021. January 25, 2022. Available at:
. Accessed November 4, 2022.
14. Durkee A. Support for gun control laws hits record high, poll finds. Forbes. June 15, 2022. Available at:
. Accessed November 5, 2022.
15. Vasilogambros M. No permit, no problem: more states allow residents to carry a hidden gun. Stateline, Pew. December 6, 2021. Available at:
. Accessed November 5, 2022.
16. Everytown for Gun Safety. State victories for gun safety. August 31, 2022. Available at:
. Accessed November 7, 2022.
17. SCOTUSblog. New York State Rifle & Pistol Association Inc. v. Bruen. Available at:
. Accessed November 7, 2022.
18. The White House. FACT SHEET: The Biden Administration cracks down on ghost guns, ensures that ATF has the leadership it needs to enforce our gun laws. April 11, 2022. Available at:
. Accessed October 28, 2022.
19. Congress.gov. S.2938 - Bipartisan Safer Communities Act 117th Congress (2021–2022). Available at:
. Accessed October 28, 2022.
20. Sakran JV, Hargarten S, Rivara FP. Coordinating a national approach to violence prevention. JAMA 2022;328:1193–1194.
21. Crifasi CK, McCourt AD, Webster DW. 202x. The Impact of Handgun Purchaser Licensing on Gun Violence. Center for Gun Policy and Research, Bloomberg School of Public Health, Johns Hopkins University. 2019. Available at:
. Accessed October 28, 2022.
22. Zeoli AM, McCourt A, Buggs S, et al. Analysis of the strength of legal firearms restrictions for perpetrators of domestic violence and their associations with intimate partner homicide. Am J Epidemiol 2018;187:1449–1455.
23. Swanson JW. Understanding the research on extreme risk protection orders: varying results, same message. Psychiatr Serv 2019;70:953–954.
24. Azrael D, Braga AA, O’Brien M. Developing the capacity to understand and prevent homicide: An evaluation of the Milwaukee Homicide Review Commission. January 2012. National Institute of Justice. Available at:
. Accessed December 30, 2022.
25. Braga AA, Weisburd D, Turchan B. Focused deterrence strategies and crime control. Criminol Public Policy 2018;17:205–250.
26. Webster DW, McCourt AD, Crifasi CK, et al. Evidence concerning the regulation of firearms design, sale, and carrying on fatal mass shootings in the United States. Criminol Public Policy 2020;19:171–212.
27. Rowhani-Rahbar A, Haviland MJ, Azrael D, Miller M. Knowledge of state gun laws among US adults in gun-owning households. JAMA Netw Open 2021;4:e2135141.
28. Rowhani-Rahbar A, Haviland MJ, Ellyson AM. Firearm policy and youth suicide—in pursuit of mechanistic explanations. JAMA Netw Open 2020;3:e2024920e2024920.
29. Miller M, Zhang W, Rowhani-Rahbar A, Azrael D. Child access prevention laws and firearm storage: results from a national survey. Am J Prev Med 2022;62:333–340.
30. Wintemute G. Background checks for firearm purchases: problem areas and recommendations to improve effectiveness. Health Aff (Millwood) 2019;38:1702–1710.
31. American College of Surgeons. ACS Committee on Trauma awarded grant by National Collaborative on Gun Violence Research. July 30, 2020. Available at:
. Accessed January 2, 2023.
32. Doucette ML, McCourt AD, Crifasi CK, Webster DW. Impact of changes to concealed carry weapons laws on fatal and nonfatal violent crime, 1980–2019. Am J Epidemiol 2022:kwac160.
33. Goodman-Bacon A. Difference-in-differences with variation in treatment timing. J Econometrics 2021;225:254–277.
34. Esposti MD, Wiebe D, Kaufman E, Bonander C. Synthetic control methodology for examining firearm policy. Curr Epidemiol Rep 2022;9:109–125.
35. Wallin MA, Holliday CN, Zeoli AM. The association of federal and state-level firearm restriction policies with intimate partner homicide: a re-analysis by race of the victim. J Interpers Violence 2022;37:NP16509–NP16533.
36. Rowhani-Rahbar A, Schleimer J, Moe C, et al. Income support policies and firearm violence prevention: a scoping review. Prev Med 2022;165PA.
37. Barber C, Frank E, Demicco R. Reducing suicides through partnerships between health professionals and gun owner groups-beyond docs vs glocks. JAMA Intern Med 2017;177:5–6.
38. Glandon D, Paina L, Alonge O, et al. 10 Best resources for community engagement in implementation research. Health Policy Plan 2017;32:1457–1465.
39. Hanson DW, Finch CF, Allegrante JP, Sleet D. Closing the gap between injury prevention research and community safety promotion practice: revisiting the public health model. Public Health Rep 2012;127:147–155.
40. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States. Ann Intern Med 2015;163:322–323.
41. Stewart RM, Kuhls DA. Firearm injury prevention: a consensus approach to reducing preventable deaths. J Trauma Acute Care Surg 2016;80:850–852.
42. Kuhls DA, Campbell BT, Thomas A, et al. Survey of American College of Surgeons members on firearm injury prevention. J Am Coll Surg 2021;233:369–382.
43. Campbell BT, Kuhls DA, Talley CL, et al. Firearm storage practices of US members of the American College of Surgeons. J Am Coll Surg 2021;233:331–336.
44. Schleimer JP, McCort CD, Shev AB, et al. Firearm purchasing and firearm violence during the coronavirus pandemic in the United States: a cross-sectional study. Injury Epidemiol 2021;8:43.
45. Buttrick N. Protective gun ownership as a coping mechanism. Perspect Psychol Sci2020;15:835–855.
46. Crifasi CK, Doucette ML, McGinty EE, et al. Storage practices of US gun owners in 2016. Am J Public Health 2018;108:532–537.
47. Vriniotis M, Barber C, Frank E, Demicco R; New Hampshire Firearm Safety Coalition. A suicide prevention campaign for firearm dealers in New Hampshire. Suicide Life Threat Behav2015;45:157–163.
48. Betz ME, Wintemute GJ. Physician counseling on firearm safety: a new kind of cultural competence. JAMA 2015;314:449–450.
49. Talley CL, Campbell BT, Jenkins DH, et al. Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago consensus I. J Am Coll Surg 2019;228:198–206.
50. World Health Organization. Social determinants of health. Available at:
. Accessed October 30, 2022.
51. Boeck MA, Wei W, Robles AJ, et al. The structural violence trap: disparities in homicide, chronic disease death, and social factors across San Francisco neighborhoods. J Am Coll Surg 2022;234:32–46.
52. Dicker RA, Thomas A, Bulger EM, et al.; ISAVE Workgroup; Members of the ISAVE Workgroup. Strategies for trauma centers to address the root causes of violence: recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma. J Am Coll Surg 2021;233:471–478.e1.
53. CDC. Violence Prevention. Adverse childhood experiences (ACEs). Available at:
. Accessed November 1, 2022.
54. Sakran JV, Ezzeddine H, Schwab WC, et al.; Patient Reported Outcome Consortium. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures. J Am Coll Surg 2020;230:819–835.
55. Walker GN, Dekker AM, Hampton DA, et al. A case for risk stratification in survivors of firearm and interpersonal violence in the urban environment. West J Emerg Med 2020;21:132–140.
56. Juillard C, Cooperman L, Allen I, et al. A decade of hospital-based violence intervention: Benefits and shortcomings. J Trauma Acute Care Surg 2016;81:1156–1161.
57. Strong BL, Shipper AG, Downton KD, Lane WG. The effects of health care-based violence intervention programs on injury recidivism and costs: a systematic review. J Trauma Acute Care Surg 2016;81:961–970.
58. Juillard C, Smith R, Anaya N, et al. Saving lives and saving money: hospital-based violence intervention is cost-effective. J Trauma Acute Care Surg 2015;78:252–257.
59. Corbin TJ, Rich JA, Bloom SL, et al. Developing a trauma-informed, emergency department-based intervention for victims of urban violence. J Trauma Dissociation 2011;12:510–525.
60. The Health Alliance for Violence Intervention. Available at:
. Accessed October 14, 2022.
61. South E, Venkataramani A, Dalembert G. Building Black wealth – the role of health systems in closing the gap. N Engl J Med 2022;387:844–849.
62. Lawmakers. Available at:
. Accessed November 1, 2022.
63. Nosyk B, Zang X, Krebs E, et al. Ending the HIV epidemic in the USA: an economic modelling study in six cities. Lancet HIV 2020;7:e491–e503.
64. New poll: voters support expanding community violence intervention as a strategy to address gun violence. August8, 2022. The Health Alliance Violence Intervention. Available at:
. Accessed October 14, 2022.
65. What is the Cardiff Model? Available at:
Accessed December 18, 2022..
66. Shepherd JP. Emergency medicine and police collaboration to prevent community violence. Ann Emerg Med 2001;38:430–437.
67. Shepherd JP. Using industry data for violence prevention. BMJ 2000;321:1481–1482.
68. Florence C, Shepherd J, Brennan I, Simon T. Effectiveness of anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury: experimental study and time series analysis. BMJ 2011;342:d3313.
69. Florence C, Shepherd J, Brennan I, Simon T. An economic evaluation of anonymised information sharing in a partnership between health services, police and local government for preventing violence-related injury. Inj Prev 2014;20:108–114
70. Levas MN, Hernandez-Meier JL, Kohlbeck S, et al. Integrating population health data on violence into the emergency department: a feasibility and implementation study. J Trauma Nurs 2018;25:149–158.
71. Mercer Kollar LM, Sumner SA, Jacoby SF, Ridgeway G. Cardiff Model Toolkit: community guidance for violence prevention. Atlanta, GADivision of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017. Available at:
. Accessed November 1, 2022.
72. Goldberg AJ, Toto JM, Kulp HR, et al. An analysis of inner-city students’ attitudes towards violence before and after participation in the “Cradle to Grave” programme. Injury 2010;41:110–115.
73. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:245–258.
74. Huffmaster CE, Williams AY, Lee YL, et al. Association between adverse childhood experiences and posttraumatic stress disorder symptoms in adults with injury. JAMA Surg 2022;157:1158–1159.
75. Narayan AJ, Rivera LM, Bernstein RE, et al. Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: a pilot study of the benevolent childhood experiences (BCEs) scale. Child Abuse Negl 2018;78:19–30.
76. Carter PM, Cook LJ, Macy ML, et al.; Pediatric Emergency Care Applied Research Network (PECARN). Individual and neighborhood characteristics of children seeking emergency department care for firearm injuries within the PECARN network. Acad Emerg Med 2017;24:803–813.
77. Schmidt CJ, Rupp L, Pizarro JM, et al. Risk and protective factors related to youth firearm violence: a scoping review and directions for future research. J Behav Med 2019;42:706–723.
78. Kalesan B, Vyliparambil MA, Bogue E, et al. Race and ethnicity, neighborhood poverty and pediatric firearm hospitalizations in the United States. Ann Epidemiol 2016;26: 1–6.e1-2.
79. Cunningham RM, Lee D, Carter PM. The role of academic medical centers in the prevention of violence and firearm-related morbidity and mortality. JAMA 2022;328:1195–1196.
80. Barron A, Hargarten S, Webb T. Gun violence education in medical school: a call to action. Teach Learn Med 2022;34:295–300.
81. Hoops K, Fahimi J, Khoeur L, et al. Consensus-driven priorities for firearm injury education among medical professionals. Acad Med 2022;97:93–104.
82. Sakran J, Lundardi N, Dawes D. Confronting the political determinants of gun violence. Sci Am October 18, 2021. Available at:
. Accessed November 1, 2022.
83. Lee L, Douglas K, Hemenway D. Crossing lines — a change in the leading cause of death among U.S. children. N Engl J Med 2022;386:1485–1487.
84. Lee LK, Fleegler EW, Goyal MK, et al.; The Council on Injury, Violence, and Poison Prevention. Firearm-related injuries and deaths in children and youth: injury prevention and harm reduction. Pediatrics 2022;150:e2022060070.
85. Dowling M, Sathya C. How U.S. businesses can help reduce gun violence in their communities. Harv Bus Rev September2022. Available at:
. Accessed November 4, 2022.
86. Marwaha JS, Lunardi N, Sakran JV. Real-world data-a key barrier to building out the science of firearm safety. JAMA Surg 2022;157:369–370.
87. Weigel J. Filmmaker Gita Pullapilly talks about telling the stories that matter. Chicago Tribune June 23, 2015. Available at:
. Accessed November 4, 2022.
88. Thomas AC, Siry-Bove BJ, Barnard LM, et al. A qualitative study on diverse perspectives and identities of firearm owners. Inj Prev 2022;28:434–439.
89. Anestis MD, Bond AE, Bryan AO, Bryan CJ. An examination of preferred messengers on firearm safety for suicide prevention. Prev Med 2021;145:106452.
90. Bond AE, Bandel SL, Anestis MD. Determining subgroups that exist among US firearm owners. Suicide Life Threat Behav 2022;52:537–548.
91. Stanley IH, Hom MA, Rogers ML, et al. Discussing firearm ownership and access as part of suicide risk assessment and prevention: “Means safety” versus “means restriction.” Arch Suicide Res 2017;21:237–253.
92. Pallin R, Siry B, Azrael D, et al. “Hey, let me hold your guns for a while”: A qualitative study of messaging for firearm suicide prevention. Behav Sci Law 2019;37:259–269.
93. Betz ME, Harkavy-Friedman J, Dreier FL, et al. Talking about “firearm injury” and “gun violence”: words matter. Am J Public Health 2021;111:2105–2110.
94. Betz M, Azrael D, Barber C, Miller M. Public opinion regarding whether speaking with patients about firearms is appropriate: results of a national survey. Ann Intern Med 2016;165:543–550.
95. Connor A, Miller M, Azrael D. Firearm safety discussions between clinicians and US adults living in households with firearms: results from a 2019 National Survey. Ann Intern Med 2021;174:725–728.
96. Simonetti J, Azrael D, Zhang W, Miller M. Receipt of clinician-derived firearm safety counseling among U.S. Veterans: Results from a 2009 national survey. Suicide Life Threat Behav 2022;52:1121–1125.
97. Sathya C, Kapoor S. Doctors, talk to your patients about guns. Sci Am April 15, 2021.
98. BulletPoints. The Bulletpoints Project: clinical tools for preventing firearm injury. Available at:
. Accessed November 5, 2022.
99. Hoops K, McCourt A, Crifasi C. The 5As of firearm safety counseling: validating a clinical counseling methodology for firearms in a simulation-based randomized controlled trial. Prev Med Rep 2022;27:101811.