Implementing a Public Health Approach to Gun Violence Prevention: The Importance of Physician Engagement FREE

The first month of 2013 brought more discussion about gun policy and more action from our state and national leaders than has occurred in decades. The release of the Vice President's task force report, the President's executive actions, and the bills in Congress and several state legislatures are all indications that the country is poised to change how it regulates access to guns.

Whether and to what extent such change occurs will depend in large part on the response from the public. Health care providers, and physicians in particular, are an important source of information for the public and a valued constituency for policymakers. Therefore, as the details of different policy proposals unfold and the public and policymakers weigh the options, we present a case for the role of physicians in these discussions.

Fifteen years ago, Dr. Frank Davidoff, then editor of Annals, called on readers to reframe gun violence as a medical issue (1). He referenced survey findings indicating that most physicians viewed gun violence as a public health problem and that they supported a more active role for the profession in preventing it. Despite Dr. Davidoff's powerful call, the New Year's resolution offered by the current editors described the efforts since 1998 as “lackluster,” citing evidence that efforts to treat gun violence as a public health problem have been undermined (2).

That reframing gun violence as a public health problem is a point of contention is difficult to understand in light of the numbers that complement the regular media reports of gun violence and its victims. In 2010, more than 31 000 persons in this country died after being shot with a gun; an estimated 73 500 more were shot and survived (3). We treat or bury, on average, 286 persons every day who find themselves on the wrong end of a gun. Although treatment of the wounds is an essential role for health care providers, it should be our last line of defense. Many gun violence victims never fully recover from their physical injuries, and the emotional scars last a lifetime. Furthermore, few of those who die from gunshot wounds could have been saved by clinical intervention. Given that more than 95% of fatalities die within 24 hours of being shot and most die where they were shot, more or better treatment is unlikely to yield substantial reductions in gun deaths (4). A greater emphasis on preventing gun violence is needed. Evidence-based, well-implemented, and enforced policies can reduce gun violence in our homes and on our streets (5), and this vision can be realized with the help of physicians.

Physicians serve an important role in identifying and providing treatment for people in crisis. Given that most (61%) gun violence victims die by their own hand, the potential for clinical intervention is powerful (3). Efforts to ensure that mental health treatment is available and that it includes options for removing guns and prohibiting new gun purchases for people who desire or would benefit from such intervention while in treatment are important. California law establishes an infrastructure for clinical providers to work with law enforcement to limit gun access when a person in treatment has made a credible threat to harm themselves or others (6). Information about how California's law is being implemented, and to what effect, can help inform clinical practice and the systems available to support that work.

Physicians can be an important voice for normalizing the dialogue around gun violence and gun policy. The latter is generally considered to be a polarizing topic, despite the fact that public opinion polls consistently show strong support among Americans for a wide range of gun policies. According to a recent survey, most people, regardless of their party affiliation or whether they own a gun, support new policies that would expand and strengthen our current regulatory approach to guns (7). For example, federal law requires licensed dealers to complete a background check on anyone who purchases a gun. This law covers an estimated 60% of gun sales but ignores the remaining 40% that are sold by unlicensed private sellers (8). As a result, buyers on the private market are not subject to the federal background check requirement. Ninety percent of the public, including 84% of gun owners and 74% of self-described National Rifle Association members, supports universal background checks for all gun sales (7). There seems to be a greater interest in what unites us on this issue. Physicians can help to encourage reasoned discussions by talking with patients and colleagues about guns and gun violence prevention.

Fear figures prominently in decisions people make about guns and has kept many quiet on this issue. Fear of strangers and chaos is the reason that some choose to be armed, whereas fear of the government is the motivation for others. Fear has also shaped the gun policy debate. Whether to muster support for “stand your ground” laws or rally in opposition to proposals that would track gun purchases to aid law enforcement investigations, fear is an element of how we talk about guns. Physicians are accustomed to helping people manage their fear of disease and death, and bringing that skill set to the current conversation about gun policy may help people manage their fear of victimization and an overreaching government.

On 16 January 2013, President Obama directed the Centers for Disease Control and Prevention to conduct research into the causes and consequences of gun violence. With that action, the President confronted the agency's 17-year silence on gun violence prevention research, which was prompted by warnings from Congress that federal funding could not be used to advocate for gun control. Ensuring that money is appropriated and that physician researchers are a part of what we predict will be a robust and effective research agenda to inform future gun violence prevention efforts are 2 ways for physicians to participate in building the evidence to inform our understanding of this problem.

A growing body of literature offers several options for evidence-based and evidence-informed policies on gun violence prevention. Those findings are described in other editorials (9 - 10) and publications (5), and we encourage readers to review and use them to inform their own advocacy.

One way to move beyond the calls to reframe gun violence and acknowledge the “raised voices” in the physician community is through leadership from within. There is a need for more physicians to talk and write about their interactions with patients and colleagues and to lead by example in the statehouses and halls of Congress.

In a democracy such as ours, the public is ultimately responsible for the state of its country. Although there are powerful and well-financed efforts that have subverted the ability of the American people to realize the common-sense gun policies they have long supported, we do not believe the public will has yet been asserted on this issue. Perhaps that is changing with the new interest being expressed, and perhaps that interest will be helped along by a physician community ready to declare that medicine and public health must be part of the response to the violence that has become such a defining feature of American life. In the words of Martin Luther King, Jr., “In the end, we will remember not the words of our enemies, but the silence of our friends.”