Reducing Firearm-Related Harms: Time for Us to Study and Speak Out
Authors: Darren B. Taichman, Christine Laine
Journal: Annals of Internal Medicine (2015)

Editorials7 April 2015Reducing Firearm-Related Harms: Time for Us to Study and Speak OutFREEDarren B. Taichman, MD, PhD, Executive Deputy Editor and Christine Laine, MD, MPH, Editor in Chief, on behalf of the Annals editors*Darren B. Taichman, MD, PhD, Executive Deputy EditorSearch for more papers by this author and Christine Laine, MD, MPH, Editor in ChiefSearch for more papers by this author, on behalf of the Annals editors*Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M15-0428 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail 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.Darren B. Taichman, MD, PhDExecutive Deputy EditorChristine Laine, MD, MPHEditor in ChiefOn behalf of the Annals Editors*References1. Wintemute GJ. The Epidemiology of Firearm Violence in the Twenty-First Century United States. Annu Rev Public Health. 2014 [Epub ahead of print 12 Dec 2014]. [PMID: 25533263] MedlineGoogle Scholar2. Centers for Disease Control and Prevention. Injury Prevention & Control: Data & Statistics (WISQARS). Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/injury/wisqars/index.html on 16 February 2015. Google Scholar3. Children's Safety Network. The Cost of Firearm Violence. Accessed at www.childrenssafetynetwork.org/sites/childrenssafetynetwork.org/files/CostofFirearmViolence_Print.pdf on 14 February 2015. Google Scholar4. Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence [Editorial]. Ann Intern Med. 2013;158:493-4. [PMID: 23277894] LinkGoogle Scholar5. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] LinkGoogle Scholar6. Hemenway D. Guns, suicide, and homicide: individual-level versus population-level studies [Editorial]. Ann Intern Med. 2014;160:134-5. [PMID: 24592499] LinkGoogle Scholar7. Institute of Medicine. Priorities for Research to Reduce the Threat of Firearm-Related Violence. Washington, DC: National Academy of Sciences; 2013. Accessed at www.iom.edu/~/media/Files/Report%20Files/2013/Firearm-Violence/FirearmViolence_RB.pdf on 18 February 2015. Google Scholar8. Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan MD, et al. Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration. A cohort study. Ann Intern Med. 2015;162:492-500. doi:10.7326/M14-2362 LinkGoogle Scholar9. Weinberger SE, Hoyt DB, Lawrence HC, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6. doi:10.7326/M15-0337 LinkGoogle Scholar10. Butkus R, Weissman A. Internists' attitudes toward prevention of firearm injury. Ann Intern Med. 2014;160:821-7. [PMID: 24722784] doi:10.7326/M13-1960 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Darren B.Taichman, MD, PhD, Christine Laine, MD, MPHAmerican College of Physicians27 May 2015 Author's Response 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. Charles JesseeSenior Research Fellow, Crime Prevention Reserach Center17 June 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 Charles JesseeSenior Research Fellow, Crime Prevention Research Center24 February 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. Author, Article, and Disclosure InformationAuthors: Darren B. Taichman, MD, PhD, Executive Deputy Editor; Christine Laine, MD, MPH, Editor in ChiefCorresponding Author: Darren B. Taichman, MD, PhD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected]org.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0428.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. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoFirearm-Related Hospitalization and Risk for Subsequent Violent Injury, Death, or Crime Perpetration Ali Rowhani-Rahbar , Douglas Zatzick , Jin Wang , Brianna M. Mills , Joseph A. Simonetti , Mary D. Fan , and Frederick P. Rivara Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association Steven E. Weinberger , David B. Hoyt , Hal C. Lawrence III , Saul Levin , Douglas E. Henley , Errol R. Alden , Dean Wilkerson , Georges C. Benjamin , and William C. Hubbard Celebrating the ACP Centennial: From the Annals Archive–Firearm-Related Harms Deborah Cotton Celebrating the ACP Centennial: From the Annals Archive–Firearm-Related Harms Deborah Cotton Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association Steven E. Weinberger , David B. Hoyt , Hal C. Lawrence III , Saul Levin , Douglas E. Henley , Errol R. Alden , Dean Wilkerson , Georges C. Benjamin , and William C. Hubbard Firearm-Related Hospitalization and Risk for Subsequent Violent Injury, Death, or Crime Perpetration Ali Rowhani-Rahbar , Douglas Zatzick , Jin Wang , Brianna M. Mills , Joseph A. Simonetti , Mary D. Fan , and Frederick P. Rivara Reducing Firearm-Related Harms Charles Jessee Reducing Firearm-Related Harms Christine Laine and Darren B. Taichman Metrics Cited byComorbidity Profiles Identified in Older Primary Care Patients Who Attempt SuicideMyth, Power, and Gun-Related Intimate Partner Violence Against WomenEffect of Remediating Blighted Vacant Land on Shootings: A Citywide Cluster Randomized TrialThe Health Care Professional's Pledge: Protecting Our Patients From Firearm InjuryChristine Laine, MD, MPH and Darren B. Taichman, MD, PhDA prospective randomized study of the efficacy of “Turning Point,” an inpatient violence intervention programFirearm-Related Injury and Death in the United StatesE. Michael Lewiecki, MDReducing Firearm-Related HarmsCharles Jessee, PhDCelebrating the ACP Centennial: From the Annals Archive–Firearm-Related HarmsDeborah Cotton, MD, MPH, Deputy Editor 7 April 2015Volume 162, Issue 7Page: 520-521KeywordsFirearm injuriesForecastingHealth careHealth surveysHomicideHospitalizationsPrevention, policy, and public healthResearch fundingSuicideVital statistics ePublished: 7 April 2015 Issue Published: 7 April 2015 Copyright & PermissionsCopyright © 2015 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...