A Call to Arms: On Complacency in Times of a Public Health Crisis

In the last four weeks on the trauma service at Washington Hospital Center, I have seen more gun violence-related injuries than any other medical condition taught in my first two years of medical school. And while the mechanism of injury is the same, the impact is different each time. I have seen the same boy come into the trauma center two separate times a few weeks apart for a gunshot wound to the leg, and leave each time with an understanding he will be back soon. I have seen a pregnant woman lose her own and her child’s life from being a bystander of a violent crime. I have seen a group of friends come in after being victims of a mass shooting outside of a popular night club. The American public has been conditioned to think of “gun control” as a political issue. It is not – it is a public health emergency. If you are under 18 and live in the United States, gun violence is more prevalent in your age group than cancer or congenital disease, and is more likely to kill you than car accidents or other injuries.¹ More Americans died in 2021 from guns than any previous year on record; there were 48,830 gun deaths in the United States in 2021, a 23% increase from 2019, and data is not even available yet from the Centers for Disease Control (CDC) for more recent years.² Yet the effect of these gun deaths go far beyond the number of lives lost, as the burden of trauma, emergency medical care, long term medical and social care for survivors of violence, loss of safety, and PTSD contribute to further morbidity and mortality for the communities and families of these individuals.³ Despite this, gun violence is not treated as an issue of public health, but instead remains within a circular and fraught political conversation. The National Rifle Association’s stronghold on Congressional legislature (the association lobbied $2.3 million in 2023),⁴ alongside the deep-seeded conviction that it is a “fundamental right for law-abiding citizens to protect themselves with firearms,” ⁵ have blocked any gun legislation and has brought us to where we are today, where gun violence is the number one cause of death for children and adolescents.¹

By shrouding the issue within politics and Constitutional interpretation, lawmakers evade regulations on guns that would otherwise apply if they were recognized as a public health concern. Consider previous public health crises that diminished once laws and policies were enacted: vaccination requirements, seat-belt requirements, and age restrictions on smoking and drinking. However, unlike past public health concerns, regulations on firearms are not feasible because of the political silo in which they exist, an immovable cornerstone of Second Amendment rights. It is not until we break the narrative of guns being a political issue that we can expect to see legislative change, or at least begin to imagine its existence.

This is not a novel idea. The CDC already discusses the role that public health approaches to violence prevention should apply to firearms, noting that firearm injuries are a “serious public health problem,” leading to over 45,000 deaths in 2020 and immeasurable long-term morbidity for individuals who survive gun violence, which can best be estimated by the 178,000 visits to the emergency department in 2021 for gun-related injuries.^6,7 The current public health approaches to addressing gun violence include research to inform prevalence data and policy solutions, yet the research is scarce. In 2023, there were only 12 available research grants allocated for gun violence with a total budget of $24 million, which pales in comparison to the total $2.231 billion spent in 2022 on the general category of “preventing the leading causes of disease, disability, and death,” including chronic disease ($1.339 billion), birth defects ($177 million), and injury ($715 million).⁸ This is not to say these other avenues are not worthy research topics, but it almost seems a mockery that the number one cause of premature death in children receives 0.5% of total funding for the leading causes of disease, disability, and death. It sends a message of complacency among public health policymakers and medical science researchers, a message that leads to 124 deaths every day.⁶

Currently, there is some programming and education available to hospitals and physicians to prepare for clinical scenarios, interventions, and counseling as it pertains to gun violence. For example, Hospital-based Violence Intervention Programs (HVIPs), one of which exists at Washington Hospital Center where I completed my trauma rotation, offer integrated social, economic, and medical care to reduce the rate of reinjury among individuals involved in gun violence, which may be up to as high as 10% within 8 years, by offering resources such as mental health treatment, housing, education, employment, and legal assistance. ^9,10 A similar program in Chicago called Cure Violence, which is based on the framework that violence is akin to infectious disease, uses community-based individuals called “interrupters” to prevent violence before it begins, just as community health workers in areas with high rates of infectious disease identify disease before it spreads.¹¹ Physician-specific education also exists. The BulletPoints Project offers a 1-hour class on how physicians can reduce the risk of firearm-related injury and death.¹² Additionally, some research findings present strategies for communicating with patients who might be a victim of violence, but who feel a sense of autonomy around guns and thus might react negatively to such interventions.¹³ However, these resources are underutilized and underdeveloped. The BulletPoints Project reports that between 2019 and 2022, only 2,106 people attended their 69 presentations.¹⁴ In respect to HVIPs, the Health Alliance for Violence Intervention reports these programs are currently in 85 cities, the vast majority of which are in California, New York, and Washington D.C. area, which is not where most gun violence occurs.^15,16 I highlight these shortcomings not to discourage the existing efforts, but instead to call to action more resources in and ownership of these issues among those in the public health and medical field.

Engagement with how to reduce the risk of gun violence is particularly important given the extent to which it most directly affects vulnerable communities and individuals of color. Data from 2020 reports that although Black males between the ages of 15-24 account for 2% of the U.S. population, they made up 38% of gun homicide deaths.¹⁷ Perhaps even more striking, the risk of being a victim of violence if you are a young Black male is 24 times that of their white counterpoints.¹⁸ These statistics are the product of historical and present structural inequities, such as housing discrimination, zoning laws, and school and education opportunities, that have made violence part of the social and economic fabric of these communities, particularly for young Black men in urban areas.^19,20 We cannot address gun violence without addressing the social inequities that underlie the issue, but it does not mean we should ignore it either. When institutions engage in conversations about health justice and health equity, they must acknowledge the glaring statistics of gun violence disproportionally affecting communities of color and work to dismantle violence at the same time as other social determinants of health.

Gun violence also is an important cornerstone of mental health, as just over half of gun violence deaths are from suicide.²¹ Suicide and mental health are linked for clear reasons of feelings of hopelessness and self-harm tendencies, as well as its intersection with substance abuse and physiological and psychotic symptoms associated with bipolar disorder and schizophrenia.²² However, research demonstrates that household gun ownership is an independent increased risk for suicide and that removal of access to firearms does not result in suicide by other means.^23,24,25 This is to say, access to guns creates an avenue for suicides that would not otherwise occur. This idea was addressed for the first time in 2013, when the Consortium for Risk-Based Firearm Policy, led by researchers and advocates in gun violence prevention, recommended state and federal level policy changes that would restrict access to firearms for individuals deemed at high risk for self-harm or violence towards others, based on either recent involuntary hospitalizations, previous violent crimes, or mental health diagnoses.²⁶ These policy recommendations have since been incorporated into law as extreme risk protection orders (ERPOs), in which community individuals can file orders to prevent high-risk individuals from accessing firearms. ERPOs currently exist in 21 states but are mostly limited to family members and law officials who can file such orders.²⁷ On a state level, this ability to file ERPOs should be extended to clinicians and health care professionals, who might be attune to an individuals’ shifting mental health and thus risk of suicide or violence. On a more regional level, more training needs to be available for physicians of all specialties on how to counsel for lethal means in patients with a demonstrated increased risk of suicide.²⁸

Congressional lawmakers may have been able to evade gun regulation by claiming it as their political property, but we can also argue that by public health officials and physicians not dedicating more attention and resources to the issue, we have wrongly absolved ourselves of guilt. Public health resources are scarce, and there are many deserving causes. However, the time has come that we must recognize this issue as our own, as we would any other threat to public health. We must call for evidence-based research, regulations, and government-level policies that better fund HVIPs or other community-intervention programs, or we are fated to accept that we are complacent in this time of crisis. In the meantime, we must be aware of community-based programs such as HVIPs and Cure Violence, and provide referrals to these workers to strengthen the programs as they exist. We must demand for a Surgeon General’s Report, which is a report written by the United States head of public health and has a precedent for shaping the landscape of public health and scientific research, as has been the case for other public health emergencies such as smoking and maternal health. We must have access to established guidelines and frameworks comparable to the PHQ-9 or GAD-7 to ask our patients about their risk of suicide by firearms.  We must provide outpatient resources to anti-violence and anti-gun programs, just as we provide referrals to nutritional clinics or alcoholic anonymous. We must educate ourselves through continued medical education and hospital-training courses on how to counsel patients after injury to prevent further harm to themselves and others. We must not ignore this issue because we do not see it as “our own” – these are our patients, this is our issue.