Darren B. Taichman, MD, PhD, Executive Deputy Editor; Christine Laine, MD, MPH, Editor in Chief; on behalf of the Annals editors (2)
This article was published online first at www.annals.org on 24 February 2015.
* Annals editors who contributed to this work are Deborah Cotton, MD, MPH; Cynthia Mulrow, MD, MSc; Jaya K. Rao, MD, MHS; Catharine Stack, PhD; and Sankey V. Williams, MD.
Requests for Single Reprints: Darren B. Taichman, MD, PhD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0428.
Taichman DB, Laine C, on behalf of the Annals editors. Reducing Firearm-Related Harms: Time for Us to Study and Speak Out. Ann Intern Med. 2015;162:520-521. doi: 10.7326/M15-0428
Download citation file:
Published: Ann Intern Med. 2015;162(7):520-521.
The numbers that describe firearm-related injury and death in the United States are astounding. Over recent years, more than 32 000 firearm-related deaths occurred annually (1). In 2013, firearms nonfatally injured 84 258 persons and killed 33 636 more, with 21 175 of these deaths being suicides (2). In 2010, firearm-related incidents cost society more than $174 billion, including more than $3 billion in direct health care costs to an already beleaguered system (3). These numbers do not include the rippling physical and emotional burdens gun-related incidents leave on those who are nonfatally wounded and the communities who lose or support injured colleagues, friends, and family. It does not matter whether we believe that guns kill people or that people kill people with guns—the result is the same: a public health crisis.
When public health crises arise, our powerful health care complex responds by doing what our scientific training and duty to help others require. We formulate questions that need answers, collect and analyze data to answer them, test hypotheses to discover remedies, study how to implement them, and monitor progress. This is how polio was nearly eliminated, automobile-related injury and death rates were reduced, tobacco-related illness decreased, and an Ebola epidemic is being curtailed. The list goes on. But it seems to stop when it comes to firearm injury. Why?
Two years ago, we called on physicians to focus on the public health threat of guns (4). The profession's relative silence was disturbing but in part explicable by our inability to study the problem. Political forces had effectively banned the Centers for Disease Control and Prevention (CDC) and other scientific agencies from funding research on gun-related injury and death. The ban worked: A recent systematic review of studies evaluating access to guns and its association with suicide and homicide identified no relevant studies published since 2005 (5, 6). However, in the wake of the horrific mass murder of children, a January 2013 Presidential executive order lifted this ban and directed the CDC to conduct research on the causes and prevention of gun violence. Obviously, this directive alone will not end the suppression of science; although research may now be “allowed,” the CDC cannot direct new resources to this task because the President's CDC budget requests to support a focus on gun-related violence were not funded. Compounding the lack of research funding is the fear among some researchers that studying guns will make them political targets and threaten their future funding even for unrelated topics.
However, study has occurred and our profession is beginning to speak more loudly.
At the CDC's request, the Institute of Medicine developed a focused research agenda designed to have an effect on firearm-related violence in 3 to 5 years (7). The Institute of Medicine committee concluded that we need a better understanding of factors associated with access to guns and their use in violence, the effectiveness of gun safety technologies or public policies at reducing gun-inflicted harm, and the influence of video games and other media. It also called for the collection of better data and database linkages to enable more effective research. These basic gaps in our knowledge are inexcusable.
In this issue, Rowhani-Rahbar and colleagues (8) begin to fill some gaps. Using probabilistic linkage, they used Washington State–wide hospitalization, criminal justice, and vital statistics records to evaluate the risks patients faced after a firearm-related hospitalization (FRH). Compared with patients with noninjury-related hospitalization, patients with an FRH were at inordinate risk for subsequent FRH (subhazard ratio, 21.2 [95% CI, 7.0 to 64.0]), firearm-related death (subhazard ratio, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (subhazard ratio, 2.7 [CI, 2.0 to 3.5]). Residential mobility, events missed by probabilistic matching, and the inability to more fully control for social or environmental confounders surely affected the precision of these estimates. Nonetheless, these findings have face validity. But are they valuable?
They are if we use them to motivate additional research to determine whether intervening at the time of an FRH can reduce future adverse outcomes. Could factors associated with increased risk help target secondary prevention strategies? Which prevention strategies are effective? Might FRH be an opportunity to break a violent cycle and promote primary prevention by avoiding others' inclusion in subsequent cycles? Currently, physicians discharge patients after an FRH with little, if any, plan to avoid the next round of violence. Shouldn't we be crying out to learn how we can work with social workers, criminologists, policymakers, and other professionals to do a better job in preventing firearm-related harm?
In another article in this issue, 7 national physician organizations are calling for measures to help us do just that (9). Executive leaders of the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, and American Psychiatric Association are together pressing for increased research (and unfettered access to the findings) to discover strategies to diminish firearm-related harms. In addition, they call for sensible measures to reduce firearm violence: universal background checks; elimination of laws intruding on physicians' and patients' rights to discuss issues related to health and safety, including guns; and restricting the manufacture and civilian sale of military-style weapons and high-capacity magazines. The American Public Health Association and the American Bar Association, which confirms that these recommendations do not conflict with Second Amendment rights or U.S. Supreme Court rulings, join these physician organizations. Together, the organizations united in this call for action represent more than 500 000 health care professional members. A recent survey of internists indicates that most believe that firearm injury is a public health issue and that physicians should get involved in its prevention (10).
Let's start. What if the more than half million health care professional members of these organizations contacted their federal and state government representatives to tell them that they believe firearm-related injury is a public health crisis that we need to fix? We just did. It took less than 1 minute to find contact information for our state government legislators (we searched “e-mail my PA legislator”). You may contact your Congressional representatives at www.house.gov/representatives/find or www.senate.gov/general/contact_information/senators_cfm.cfm. We provide a copy of the letter we sent (Supplement), and you can modify it or write your own to convey your thoughts on the public health threat of firearms.
We, as health care professionals, are trusted, expected, and paid to prevent harm to our patients and discover solutions to public health problems. Have we done our jobs? Can we? The answers are no and maybe: No, we have not sufficiently reduced the firearm-related harms our patients suffer, but maybe we can, if we demand the resources and freedom to do so.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Senior Research Fellow, Crime Prevention Research Center
February 24, 2015
Facts and Beliefs in Medicine
Beliefs abound in the debate on firearms and society, but one would hope facts prevail in the academic literature on firearms and public health. As a charged political issue, this is often not the case, as evidenced in this editorial."The profession's relative silence was disturbing but in part explicable by our inability to study the problem. Political forces had effectively banned the Centers for Disease Control and Prevention (CDC) and other scientific agencies from funding research on gun-related injury and death. The ban worked: A recent systematic review of studies evaluating access to guns and its association with suicide and homicide identified no relevant studies published since 2005"While a widely promoted belief, based on mass media coverage of a white paper published by a un control organization (the former Mayors Against Illegal Guns, now Everytown for Gun Safety) , the literature on firearms has increased markedly in recent years, as reported by John Lott (Crime Prevention Research Center). http://johnrlott.tripod.com/Did_Federal_Fund_Cuts_Really_Stop_Gun_Control_Research_Final.pdf Only a biased analysis of the literature produced the conclusion that the CDC funding limitation blocked firearms research publications. Such rebuttals rarely find their way into the medical literature, but often emerge in econometrics and criminal research journals. Indeed, I have had many Letters to the Editor rejected or outright ignored when attempting to correct beliefs with facts on firearms.Note that non-governmental funding, largely from organizations that advocate gun control, often supports published medical research on firearms, with no conflict of interest disclosed. Many university "Gun Violence" centers rely on funding from such organizations (Joyce Foundation, etc.), typically one step removed from strongly biased donors such as Bloomberg, Soros, etc.As noted in the other editorial referenced in this issue "Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association", a number of medical organizations have joined in advocacy of gun control measure based on other beliefs regarding firearms, without factual merit: "Although evidence to document the effectiveness of the Federal Assault Weapons Ban of 1994 on the reduction of overall firearm-related injuries and deaths is limited, our organizations believe that a common-sense approach compels restrictions for civilian use on the manufacture and sale of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. It seems that such restrictions could only reduce the risk for casualties associated with mass shootings."Note that the limited evidence supporting an Assault-Weapons Ban was a an early report only a year or so into the 10-year ban, and that the final report found no discernible impact of the AWB. http://www.wsj.com/articles/SB10001424127887323468604578245803845796068Similarly, the stance taken on universal background checks is driven by the myth that 40% of gun transfers occur without background checks, based on a study largely conducted before the Brady background checks system was in operation.Why ask for more research funds, yet ignore research that doesn't support desired outcomes and "common-sense" beliefs? The belief that ends justify means has no place in academic medical discourse and peer-reviewed medical literature. Silencing opposition is a shameful means of attempting to achieve ends.
Darren B.Taichman, MD, PhD, Christine Laine, MD, MPH
American College of Physicians
May 27, 2015
Mr. Jessee cites several sources that support his views about restrictions on firearms research and the effectiveness of strategies to reduce the firearm violence. While Figures 2 and 3 in the Crime Prevention Research Center report that Mr. Jessee refers to in his letter do not show a reduction in published articles about firearms following the 1996 and 2011 restrictions on the use of government funding for firearms research, Figure 1 of that report demonstrates an increase from about 3 firearms articles/10,000 medical journal articles in 1985 to 15/10,000 in 1996 when the CDC restrictions were instituted and a subsequent decline to 5/10,000 by 2011. It is important to note several things that support our belief that too little research is done on firearm-related injuries and death given the number of lives affected each year in our country. First, the number of firearms articles is remarkably tiny given the large number of lives damaged by or lost to guns. Second, given the restrictions that were in place, the articles published following the restrictions were likely unfunded or had funding from non-governmental sources that place a priority on reducing firearm-related injury and death. Had funding been available from CDC, NIH, and other governmental sources the amount of research and published articles on firearms would surely have been much larger. Finally, we interact with many public health researchers on a regular basis who are reluctant to study or comment on firearms for fear that doing so would compromise funding for the other conditions they study. Regardless of the impact of the 1996 and 2011 restrictions on numbers of published articles, it seems very clear that we are lacking sufficient high quality research to guide evidence-based policies to reduce firearm-related injury and death. This is true of policies on background checks prior to gun purchases, ownership of assault weapons, safety devices on guns, and a myriad of other policies that could have an important impact on the adverse effects guns have on the health and longevity of too many Americans. Finally, we could not agree more with Mr. Jessee that silencing opposition is a shameful means of attempting to achieve ends.
Senior Research Fellow, Crime Prevention Reserach Center
June 16, 2015
Rate vs Volume of Firearms Literature
Dr. Taichman has provided a thoughtful response to my initial comment, for which I thank him. Indeed, this is one of the few journals that either allow comments, or don't purge dissenting comments. In reviewing his reply, I would note that his description of the content of Figure 1 in the Whitley & Lott 2014 white paper does match that presentation provided in Bloomberg's "Mayors Against Guns" white paper, showing the rate of firearms-related articles per 100,000 medical journal articles did decline between 1996 and 2011, dates coincident with the law restricting CDC funding and Obama's Executive Order skirting the law. The essential point of Whitley & Lott 2014 is that the *volume* of firearms-related publications did not decrease during this period. The relative volume of all medical journal articles simply increased, leading to an apparent decrease in the rate of firearms-related papers (see Figure 2). PUBMED citations increased 55% between 1996 and 2011, but it doesn’t necessarily mean firearms-related papers should parallel that increase. According to the Bureau of Justice Statistics: “Handgun-involved incidents [homicides] increased sharply in the late 1980s and early 1990s before falling to a low in 2008” and ” Firearm-related homicides declined 39%, from 18,253 in 1993 to 11,101 in 2011.” For those contending that guns are a disease, is it not surprising that when the disease ebbs, so does research funding? That said, as Dr. Taichman notes, the maintenance of the firearms-related literature volume appears to have been taken up by private “non-governmental sources that place a priority on reducing firearm-related injury and death.” Many of these sources once self-identified as "Gun Control" advocates, but revised their image to "Gun Safety" advocates, to avoid 2nd Amendment issues. Consider the text of the “ban” itself: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” With the expressed goal “…to reduce the number of handguns in private ownership, starting with a 25% reduction by the turn of the century,” it’s not hard to see how such funding fell under scrutiny by NRA, other gun-rights advocacy groups, and conservative politicians. Repression of new firearms research and researchers is indeed spoken of by those who had derived funding, or might derive future funding, for firearms research. But a new generation of firearms researchers funded (albeit indirectly) by billionaires Bloomberg and Soros, and Obama’s assembly of foundations with firearms policy as an advocated objective (Joyce, Robert Wood Johnson, etc.) has more than redoubled their ranks. Johns Hopkins School of Public Health Center for Firearms Policy and Research, Harvard Injury Control Research Center, and many other public institutions, are expanding faculty and publishing at an up-ticked rate Their Media/Press staff are working hard to see any ‘online-before-print’ article multiply echoed on mainstream news channels. Payback for “silencing” the CDC’s firearms research funding? Perhaps the pendulum has swung to far, when "Rock Star" academics are sought for news and talk-show interviews before the larger academic community has a first-glimpse and chance to comment on the research
Cardiology, Hospital Medicine, Infectious Disease, Neurology, Healthcare Delivery and Policy.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only