How to Move the Conversation on the Public Health Crisis of Gun Violence

July 2016
David Vlahov

Over the last weeks, the violence in Louisiana, Minnesota and Dallas shook the nation. Stark images of the shooting deaths of black men through streaming video escalated the issues of firearm fatalities, systemic racism and excessive police violence. The ambush and shooting deaths of the Dallas and Baton Rouge police officers stunned us. We mourn and express our condolences to the relatives and friends whose loss is personal and to communities whose trauma is collective.

However, as health care professionals, we cannot leave it at that; we cannot sit still while efforts to address these calamities continue to be frustrated. Nurses need to be among those helping the nation make sense of the conversation.

The issues are undeniably complex, involving guns, race, class and culture. Our focus in this piece is on guns, but we promise further conversation about race, class and culture in later installments of Science of Caring.

According to the Centers for Disease Control and Prevention (CDC), firearm-related fatalities are among the top five leading causes of injury-related death. Suicides account for 63 percent of fatal firearm violence, but are more common among whites, and the number has been increasing over the past decade. Homicide rates have been on the decline in the past decade, but are more concentrated among black males, where high rates have remained relatively unchanged over time. Mass shootings garner headlines, but they represent less than one percent of all gun-related deaths. 

Then there is the issue of mental illness and guns, which is widely misunderstood. As Dr. Jeffrey Swanson, a professor in psychiatry and behavioral sciences at Duke University School of Medicine, put it recently: “Mental illness is a strong risk factor for suicide. It’s not a strong risk factor for homicide,” though he made it clear that almost by definition, inflicting violence on large groups of people is a type of mental illness. All of these findings appear to have implications for possible interventions, but we need more data to intelligently inform the design of policy and practice.

Unfortunately, there have been no government-sponsored studies about how to prevent firearm deaths and injuries since 1997, when the Dickey amendment was added to a US House of Representatives bill. The amendment stated that the CDC may not conduct any studies that “advocate or promote gun control.” In 2012, that prohibition was expanded to the entire Department of Health and Human Services.

The restriction on research means that it’s difficult to objectively evaluate the potential efficacy of any proposed gun control laws. In 2003, when the Task Force on Community Preventive Services issued its first report evaluating the effectiveness of strategies to prevent violence, it concluded that there was insufficient evidence to make any determination.

In an effort to change the dynamic after the Sandy Hook Elementary School massacre, which took place in Newtown, Connecticut, in December 2012, Vice President Biden called for the Institute of Medicine to conduct a review and provide a report on firearm-related research. I served on the panel that released the report in June 2013, Priorities for Research to Reduce the Threat of Firearm-Related Violence. We highlighted significant gaps in knowledge to formulate prevention strategies and proposed a research agenda – designed to produce results in three to five years – which focuses on the characteristics of firearm violence, risk and protective factors, interventions and strategies, the impact of gun safety technology and the potential influence of video games and other media. Yet with Congress stalled on providing funding, the research has lagged, although some private foundations have stepped forward.

Nevertheless, even in the absence of all the necessary research, there are some commonsense approaches clinicians should be able to bring to their patient encounters. Last year, at least 265 children under 18 years old picked up a firearm and shot someone by accident; 83 of those incidents were fatal, and about half of the fatalities were the children themselves. Given the public health costs, we should be able to have conversations about gun safety with our patients, but legislators block that as well. When Florida legislators instituted a “physician gag law” that forbade even an assessment of gun safety, organized medicine took them to court, arguing that such laws interfere with their First Amendment rights. They lost on appeal and the gag order remains in effect. According to the Law Center to Prevent Gun Violence, similar legislation has been introduced in 14 states, and watered-down versions of Florida’s gag law have been enacted in Minnesota, Missouri and Montana.

Nurses, I’m proud to say, are standing up to these restrictions in many different ways. Recently, American Nurses Association President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, declared after the recent tragedy at Pulse nightclub in Orlando, “Now is the time to enact meaningful gun control legislation at the state and federal level to protect society…. We all must join with other members of our community and at every level of civil society in dialogue and action to address the underlying issues that result in hate and motivate unspeakable acts of violence.”

The Emergency Nurses Association has also taken a strong position that as health care consumer advocates, nurses must educate the public about the risks of improperly stored firearms and support the creation and evaluation of community and school-based programs targeting the prevention of firearm injuries. They also support the establishment of a national database of reportable firearm injuries to make evidence-based decisions regarding patient care, safety and prevention. Moreover, they recognize that the most effective way to keep children from unintentional firearm injury is to limit access.

Quite appropriately, the ENA also points to where the literature is unclear. Despite the organization’s belief in education, they acknowledge that data are limited and mixed on the effectiveness of existing strategies for education of children. Which brings us back to the key point: Ill-advised restraints continue to hamper efforts to develop the evidence base we need for a public health approach to reducing firearm fatalities and injuries. I join with many others in calling for a national database and a robust research effort that can support public health clinicians in our efforts to stop the firearm-related deaths and injuries.

And on the subject of what clinicians can do, I know of a nurse who felt that discussions with patients about gun safety were better left to gun safety experts. I disagree. As nurses, we can’t pass off the responsibility. We are witnesses to the carnage and we see the aftermath. We have a moral responsibility to be actively engaged, both with our patients and in this national debate, bringing not just our clinical expertise and perspective but also our commitment to generating the data that underpins rational policy and advocacy. We should contribute and, at times, lead the conversation on how clinicians can help the cause of gun safety, and we should unabashedly advocate for the health and safety of our patients and our communities.