What Can Doctors Do To Reduce Gun Violence? Tell Us What Only They Know.

Next week’s issue of the New England Journal of Medicine will contain an editorial, “Guns, Society and Medicine,” written by the Journal’s former editor, Jerome Kassirer.  This editorial follows hard on the heels of another editorial, “Preventing Firearm Injury and Death” which just appeared in the Annals of Internal Medicine.  The good news about these statements is that they appear to reflect a growing consensus in the medical community that physicians should play a more active role in the debate about guns.  The bad news, it seems to me, is that the manner in which physicians appear to be lining up to engage in the debate may actually diminish the value of what they have to say.

The statement in the Annals, signed off by eight medical professional organizations (AAP, ACEP, ACP, etc.) calls for vigorous support of the following measures: universal background checks, elimination of physician “gag” laws, restrictions on the sale of assault rifles and high-capacity feeding devices, additional research, improved mental health services and avoidance of stigmatization through non-specific reporting laws.  These measures were adopted by the eight medical societies after the American Bar Association confirmed that they did not conflict with 2nd-Amendment rights.

conference program pic                In his NEJM editorial, Jerome Kassirer voices his support for these same measures but notes that gun-safety advocates appear to be losing the battle due primarily to the “reality that gun-control advocates are ’outgunned’  by the NRA.”  It should be noted, inter alia, that in the twelve months following Sandy Hook, dues received by the NRA jumped more than 60% from $108 million in 2012 to $175 million in 2013, an increase due to the ability of the organization to sell the idea that the public outcry over what happened in Newtown would result in all guns being taken away.

I have been listening to gun-safety advocates bemoan the political power and financial muscle of the NRA for more than twenty years while, at the same time, researchers continue to publish articles which rightly demonstrate that the losses from gun ownership outweigh the gains.  There simply is no question that scholars like Hemenway, Cook, Webster and so many others have produced a body of literature about gun risk that cannot be honestly challenged by the other side.  But the other side isn’t interested in participating in a scholarly debate.  The other side is interested in selling guns.  And as long as guns are legal commerce, why shouldn’t it be up to the individual consumer to decide whether gun ownership represents a risk?

The answer to that question, and the role that I believe physicians should play in the gun debate can be found in a substantive piece of research that was also published this week in the Annals.  This work covered the medical histories of everyone discharged in 2006-2007 from an ER in Washington State and found that the patients who were admitted for a gun injury, particularly if they had a previous gun or violence-related arrest, had a significantly higher chance of coming either back to the ER with another injury or winding up in the morgue.  The research plan focused primarily on more than 9,000 patients who were treated for violent injuries, of whom 680 were in the ER because they were injured with guns.

What seems to be missing from the recommendations to reduce gun violence proposed by the medical associations and echoed by Dr. Kassirer is the fact that in the Seattle study, each of those 680 patients represented at least one direct, face-to-face contact with a clinician who had to deal with the medical risk of guns.  Thanks to data mining, we know a lot about the demographic profiles of these patients, but only the physician who treated them was in a position to ask and possibly learn what happened, why it happened, and whether it would happen again.  The answers to those questions and how those answers could shape policy, is a contribution to the gun debate that only doctors can make.

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Is Gun Violence A Recurring Disease? A New Study Says ‘Yes.’

What are the odds that someone who is discharged from a hospital after treatment for a gunshot injury will return to the hospital with another serious injury or will be arrested for committing a serious crime?  For the first time a study attempts to answer that question based on enough data to discuss how the medical community should respond to people who seek medical help after being assaulted with a gun.  The Annals of Internal Medicine contains a study of more than 9,000 patients who were admitted to hospitals in Washington State with violent injuries in 2006-2007 and were then followed through December, 2011 or to their next subsequent hospitalization, arrest, or death, or whichever came first.  The findings about this group were then compared to 68,000 patients who were discharged during the same two-year period but had been treated for non-violent injury, along with a comparison to 180,000 patients comprising the general population.

conference program pic                Before we compare the long-term experiences of all three groups, let’s look at the composition of the violent injury group itself.  Of all patients treated between 2006 and 2007 for violent injury, roughly 7.5% were admitted for injuries involving guns, or what the researchers refer to as firearm-related hospitalizations or FRH.  But the FRH number was actually 21% of all assaults, since 65% of all serious injuries were self-inflicted (accidents and the like.)  The ratio of one out of five assaults in which a gun was used is no different from what the FBI reports across the nation as a whole.

Patients admitted in 2006-2007 for gun injuries were also typical of this population in general, with nearly 75% being less than 40 years old, and 85% being male.  Racial data was not available for this study, but interestingly, one-third of all victims of gun violence in Washington State paid their hospital bills with private insurance, whereas the Urban Institute recently calculated that less than 5% of all hospital admissions for gun-related violence were covered by private plans.

Here’s the bottom line.  A patient who was treated and discharged for a gun injury in 2006 and 2007 had a significantly higher chance of then being killed with a gun or being arrested for some kind of violent assault.  A history of criminality prior to the hospitalization increased the likelihood of post-discharge victimization or criminal behavior even further.  The point is that a medical encounter for the treatment of gun violence does not just represent a challenge to respond to the injuries caused by the specific gun-related event.  It is also a harbinger of further medical challenges to come and should be understood and responded to in the context of an ongoing and continuous medical risk.

Other studies have also shown that violent injury is a recurring disease.  Earlier this year JAMA Pediatrics published an article which showed a clear division between two youthful populations, ages 14-24, who were treated by Emergency Departments in Flint, MI.  The groups were divided between those patients whose first visit to the ER was for violent injury, the other group came to the ER for something else.  What then happened was that a significant number of the patients who first sought medical care for injury returned to seek care for the same problem again. Not a single member of the latter population that came to the ER for something other than violent injury ever sought medical care for any kind of serious assault.

The Annals issue containing the study on violent recidivism also held an editorial in which eight of the major medical associations (ACP, AECP, AAP, ACS, etc.,) called for stronger physician commitment and endorsed a list of public health initiatives to deal with the medical risks of guns.  But I think that physicians need to do more than just support public health strategies in this regard.  What they really should do is develop effective medical strategies based on research like the articles cited above.  After all, it’s ultimately what the doctor tells the patient which makes any difference at all.

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Do We Understand Gun Violence? Not Yet.

Yesterday a very important article appeared in the Annals of Internal Medicine that once again appears to demonstrate a strong link between homicide and suicide rates and availability of firearms.  The authors, led by Andrew Anglemyer of the University of California, San Francisco, conducted an extensive search of all relevant published and unpublished studies, compared, synthesized and correlated results and confirmed that access to firearms “is associated with risk for completed suicide and being the victim of homicide.”

This is not a new piece of news for the public health community, although it will be viewed with suspicion and distrust by groups like the NRA that view everything about guns produced by public health researchers with suspicion and distrust.  Research on links between guns and violence directed either outward or inward has been going on since the early 1990’s and the results always seem to be the same.  To quote my favorite authority on the subject of gun violence, the author Walter Mosley, “If you carry a gun, it’s bound to go off sooner or later.”

Union St., Springfield, MA

Union St., Springfield, MA

But now that we have exhaustively shown when the gun will go off, either in a homicide or a suicide, the problem still remains to figure out the why.  Because even though 30,000 gun homicides and suicides is a big number, let’s not forget that there are some 35 million homes where guns can be found, which means that somewhere around 90 million people have access to those guns, which means that roughly 89,970,000 Americans who could have used a gun to commit a homicide or a suicide chose not to do so.

What we usually do is to figure out where the people live who use guns to hurt themselves or others, and once we figure that out, then we try to identify the users themselves.  Which is easy to do in the case of suicides, because the shooter and the victim are both lying there on the floor.  It’s less easy to figure out in the case of homicides, where a police department that makes an arrest in more than one out of every two homicides is doing a pretty good job.   What we don’t seem to do is what David Hemenway calls the “individual-level studies of perpetrators;” in other words, why do certain people carry and use guns?”

The answer tends to focus on what Hemenway calls “ecological” studies which make connections between gun violence and the socio-economic factors that create environments in which high levels of gun violence occur.  And we now know that if we look at a community or a neighborhood with high rates of violence and gun homicide, we can usually also find high rates of unemployment, family dysfunction, educational underachievement and the usual list of inner-city ills.

With all due respect to this scholarship however, and I have nothing but admiration for the many dedicated researchers who have been studying this problem for, lo these many years, I also think they are ignoring one important point.  The multi-family dwelling pictured above is the location in Springfield, MA, of at least three and possibly four homicides over the last 19 months.  The area within one-quarter mile of this address contains every facility and resource that the 4,000 residents of that area ever use: school, church, hospital, community center, police station, playground, supermarket, deli and fast foods.

The city of Springfield had 25 homicides over the last 19 months and 4 of them happened here.  Springfield had a homicide rate per 100,000 of 12 – three times the national average – but this street had a homicide rate of 50 per 100,000.  And they didn’t all happen in one day.  They were spread out over 19 months and the most recent occurred last week.

I wouldn’t be surprised if what goes on in front of 435 Union Street in Springfield is what goes on in every city where high levels of gun homicides take place.   It’s not just about the demographics of the inner city, because even on bloody Union Street 3,996 of the 4,000 neighborhood residents haven’t found a reason to pull out a gun. Hemenway is correct when he calls for individual-level studies of shooters, but some way will have to be found to study them one at a time.

 

Should Physicians Advocate for More Gun Control? Of Course They Should

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A remarkable article on gun safety advocacy by physicians has recently been published in the Annals of Internal Medicine.  Written by three public health specialists, it calls for physicians and other health care professionals to be more aggressive in advocating measures to cut gun violence.  What’s remarkable about the article is not what it says, but the fact that it has been published at all.  Because despite the overwhelming evidence that the existence of several hundred million guns is coincident with the highest levels of gun violence of any advanced country, physicians of late have been reluctant to play the role of advocates in the gun violence debate.

The self-imposed constraint on gun safety advocacy goes back to the firestorm that was ignited by physicians who were one of many groups that called for stricter gun controls, if not some degree of outright abolition of guns, during the public debates that led up to the passage of the assault weapons ban and Brady laws in 1993-94.  In retaliation, the NRA launched a successful campaign to defund the CDC from sponsoring gun research, and continues its barrage of nonsensical claims about the inherent value of guns to protect us from crime and violence.  Worse, many of these so-called “studies” are the handiwork of individuals who use their alleged medical credentials to promote social and political agendas that go far beyond any rational discussion about guns or anything else.

One of the latest salvos is the handiwork of an Arizona internist, Jane Orient, who recently published a survey of gun control research in the Journal of American Physicians and Surgeons, an organization which can best be described as “libertarianism meets medicine.”  Now don’t get me wrong.  Physicians have as much right to organize and advocate for any political position as anyone else.  They also have the right to publicly criticize any and all government policies that affect their work as physicians.  But there is a difference between using your status as a medical professional to challenge medical procedures or policies, as opposed to promoting a political agenda based on unproven claims masquerading as medical research.

There is simply no valid proof to the continuous claims made by NRA-leaning researchers that a positive correlation exists between private ownership of guns and decreases in crime rates.  The best the pro-gun crowd can offer are studies that show a decline in gun violence coincident with an increase in concealed-carry licensing.  But what do they say when a jurisdiction like New York City sees a significant drop in violent crime while, at the same time, refusing to relax its stringent gun control laws at all?  The silence is deafening.  The truth is that Dr. Orient and her followers are opposed to gun control because they are opposed to all government regulations, not just as they might apply to guns, but as they apply to environment, financial activities and, of course, the practice of medicine itself.

On the other hand, when serious research on gun violence is done by serious medical and public health researchers, they need to put as much time and energy into publicizing the results as they spend in doing the research itself.  Sending a press release to the gun control lobby, like the Brady Campaign or The Coalition to Stop Gun Violence does nothing to mitigate the pro-gun advocacy work of Jane Orient and her like-minded friends.  But if the American Academy of Pediatrics decided it wanted to tell the world about a new study on school bullying, I guarantee they would send something to every PTA.  I’m really glad that a few voices are finally speaking up for the necessity of more physician advocacy about guns.  Like I said yesterday, I just want a fair fight, and for that to take place, the medical community has to get back into the fray.