Public Health Research on Gun Violence: Long Overdue
Authors: Victor J. Dzau, Alan I. Leshner
Journal: Annals of Internal Medicine (2018)

Ideas and Opinions19 June 2018Public Health Research on Gun Violence: Long OverdueFREEVictor J. Dzau, MD and Alan I. Leshner, PhDVictor J. Dzau, MDNational Academy of Medicine, Washington, DC (V.J.D.) and Alan I. Leshner, PhDPotomac, Maryland (A.I.L.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-0579 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Gun violence is a defining public health challenge of our time. As the United States grapples with the shooting deaths of 17 people in Parkland, Florida, on 14 February 2018, the medical and public health communities must step up and do our share to prevent such devastation from recurring. Effective public health strategies have reduced such threats as motor vehicle injury, tobacco use, accidental poisonings, and drownings. Effective strategies are built on research to identify patterns of risk, illuminate productive targets for intervention, and assess the effectiveness of interventions. Unfortunately, the United States lacks a comprehensive public health approach to gun violence, due in large part to the absence of federal funding for research on gun violence for more than 2 decades.In 2013, after the tragedy at Sandy Hook Elementary School, President Obama directed federal agencies to mount research programs to improve understanding of the causes of gun violence and interventions to reduce it. As a result, the Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine (IOM) and the National Research Council (NRC) to define a public health research agenda for gun violence. The resulting consensus report, "Priorities for Research to Reduce the Threat of Firearm-Related Violence," laid out the highest-priority research questions to effect progress in a 3- to 5-year time frame (1). These recommendations remain relevant and may be even more urgent today. Without research, policymakers are flying blind when they propose new laws or policies.A provision in a 1996 omnibus spending bill known as the Dickey Amendment forbade the CDC from using its funds to promote or advocate for gun control. This was interpreted as a prohibition on supporting any research on firearms, and the CDC program was dismantled. As a result, we lack even the most basic information about the prevalence and safety of firearms in the United States, as well as data on the effectiveness of interventions aimed at reducing the probability of injury and death related to their use.The shooting in Parkland has prompted renewed calls for research, including from members of Congress. The 2013 IOM/NRC report provides an immediately actionable blueprint to advance such an agenda. The report notes that public health research should be integrated with insights from criminal justice and other fields because no single agency or research strategy can provide all of the answers. The proposed research agenda focuses on characteristics of firearm violence, risk and protective factors, interventions and strategies, the effects of gun safety technology, and the influence of video games and other media.To develop effective strategies to reduce firearm injury and death, it is important to understand what is and what is not known. We lack good data on the number and types of guns in the United States. We need to understand the scope and nature of gun acquisition, ownership, and use across the U.S. population, especially among groups at risk for perpetrating or experiencing gun violence. To protect civil liberties, these data should be collected anonymously. We also need good data on fatal and nonfatal gun incidents, including the proportions that are accidental versus intentional.Factors that may influence the risk posed by guns range from how securely they are stored to complex predictors at the societal, community, situational, and individual levels. At the individual level, risk for perpetration of gun violence coincides with low educational attainment, substance use, and a history of aggression and abuse. In the home, secure storage of guns and accessibility by children are areas of major concern. At the community level, poverty and drug trafficking are known to increase the risk for violence, and at the societal level, cultural norms that promote violence as an acceptable means of conflict resolution may be harmful. These are just a few of the many factors that may relate to risk for gun violence. Only dedicated research can reveal which of these factors, alone or in combination, are the most promising targets for intervention.It is important for research agendas to include evaluations of the effectiveness of interventions to prevent gun violence. Recently, various interventions have been proposed or implemented, such as firearm safety education programs or modifications to the physical environment, including installation of metal detectors. However, we lack conclusive evidence about their effectiveness. Policymakers should be wary of potential unintended consequences of untested "solutions."Firearm technologies may provide an important opportunity to reduce the public health burden of gun-related injury. Like an airbag in a car or a childproof cap on a pill bottle, the objectives of firearm technologies range from preventing unintentional shootings by young children to reducing suicide. The IOM/NRC report argued that research should examine product safety measures. Specifically, the report proposes research to identify the effects of different technologies designed to reduce firearm injury and death and to explore state and international policy approaches to firearm safety technology for applicability to the United States.Finally, the IOM/NRC report advocated for study of the influence of video games and other media on violence. In more than 50 years of research, no study has focused on real-life firearm violence as a specific outcome of violence in media. As a result, a direct relationship between the two is unproven.If implemented, the public health research agenda proposed in the 2013 IOM/NRC report would provide knowledge to inform our nation's approach to minimizing firearm-related violence and its effects on the health of the U.S. public. Scientific evidence generated by this research would enable the development of sound policies that support the rights and responsibilities central to gun ownership in the United States. It is time to bring the full power of science to bear to deal with this issue of such great concern to our country. We need researchers from different disciplines, including public health, social and behavioral sciences, mental health, and law enforcement, to work together to tackle this problem. That can only happen if we restore the much-needed research funding. It is time to end the counterproductive research freeze.Reference1. Institute of Medicine; National Research Council. Priorities for Research to Reduce the Threat of Firearm-Related Violence. Washington, DC: National Academies Pr; 2013. doi:10.17226/18319 CrossrefGoogle Scholar Comments0 CommentsSign In to Submit A Comment Robert B. Sklaroff, M.D.Nazareth Hospital9 July 2018 Public Health Research on Gun Violence: Long Overdue Public health research on gun violence is long overdue (1), but it must NOT be politicized. Reflexly touted is the Institute of Medicine's distillation of "Priorities for Research to Reduce the Threat of Firearm-Related Violence" (2), but intuitive omissions therefrom threaten to impugn the quality of any quasi-scientific initiative based solely thereupon.Overtly insufficient was "the research program envisioned by the committee (designed to produce impacts in 3-5 years) that focuses on [1]—the characteristics of firearm violence, [2]—risk and protective factors, [3]—interventions and strategies, [4]—gun safety technology, and [5]—the influence of video games and other media."This presumably comprehensive formulation evades the necessity to assess the impact of irrefutable parameters that are recognized in the lay literature. For example, Broward County Sheriff Scott Israel faced criticism for his department's repeated failures to stop the Florida school shooter Nikolas Cruz at the Marjory Stoneman Douglas High School in Parkland, Florida (3); indeed, the Broward County school district's adoption of a lax school discipline policy—praised by the Obama administration for seeking to reduce the reported number of school suspensions, expulsions, and arrests—may have helped Nikolas Cruz remain under-the-radar until his shooting rampage (4).The only specific parameter that could encompass these concerns is intent to "Improve understanding of the effectiveness of actions directed at preventing access to firearms by violence-prone individuals." Omitted is any effort to probe the pattern of institutional failures that occurred in Broward— encompassing school officials, government personnel and social workers—recognizing that police department failures indubitably transpired before (negligent house-calls), during (inexcusable cowardice) and after (CNN Town Hall) the mass-shooting.Ignored is the specter of unjustified gun confiscation threatening Second Amendment rights as sustained by the Supreme Court, which has prematurely been instituted in American communities. Ignored is the necessity to focus upon the sufficiency of treatment of mental illness. Ignored is the need to accommodate non-sharpshooters who may not wish to limit the number of bullets they can discharge from a firearm upon which they would depend for self-defense.As explored during discussion of the accompanying call-to-arms (5), interventions must be based on data that are accepted by responsible thinkers on all sides of this ongoing debate, transcending perennial polemics. This will preclude adopting a sense of resignation (e.g., "Chicago hoodlums inevitably get out-of-state guns"), as consensus development is stripped of those seeking only to validate preconceived notions. 1. Dzau VJ & Leshner AI. Public Health Research on Gun Violence: Long Overdue. Ann Intern Med. 2018;168(12):876-877. Accessed on 7/7/2018: http://annals.org/aim/fullarticle/2675740/public-health-research-gun-violence-long-overdue 2. Institute of Medicine; National Research Council - Priorities for Research to Reduce the Threat of Firearm-Related Violence. Washington, D.C. National Academies Pr, 2013. Accessed on 7/7/2018: http://www.nationalacademies.org/hmd/Reports/2013/Priorities-for-Research-to-Reduce-the-Threat-of-Firearm-Related-Violence/Report-Brief060513.aspx 3. Domenech B. Sheriff Scott Israel Exemplifies the Failures of Our Institutions. Accessed on 7/7/2018: http://thefederalist.com/2018/02/26/sheriff-scott-israel-exemplifies-the-failures-of-our-institutions/4. Berry S. Broward County Likely 'Inspiration' for Obama School Discipline Policy to Report Fewer Arrests, Suspensions (2/26/2018). Accessed on 7/7/2018: https://www.breitbart.com/big-government/2018/02/26/broward-county-likely-inspiration-for-obama-school-discipline-policy-to-report-fewer-arrests-suspensions/.5. The Editors. Editors' Note: Call for Articles on Firearm-Related Harm. Ann Intern Med. 2018;168(12):887. Accessed on 7/7/2018: http://annals.org/aim/fullarticle/2675741/editors-note-call-articles-firearm-related-harm. Author, Article, and Disclosure InformationAffiliations: National Academy of Medicine, Washington, DC (V.J.D.)Potomac, Maryland (A.I.L.)Note: Dr. Dzau is president of the National Academy of Medicine (formerly the Institute of Medicine). Dr. Leshner is CEO emeritus of the American Association for the Advancement of Science and chair of the committee that authored "Priorities for Research to Reduce the Threat of Firearm-Related Violence."Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0579.Corresponding Author: Victor J. Dzau, MD, National Academy of Medicine, 500 5th Street NW, Washington, DC 20001.Current Author Addresses: Dr. Dzau: National Academy of Medicine, 500 5th Street, NW, Washington, DC 20001.Dr. Leshner: 12118 Little Creek Drive, Potomac, MD 20854.Author Contributions: Conception and design: V.J. Dzau, A.I. Leshner.Drafting of the article: V.J. Dzau, A.I. Leshner.Critical revision of the article for important intellectual content: V.J. Dzau, A.I. Leshner.Final approval of the article: V.J. Dzau, A.I. Leshner.This article was published at Annals.org on 20 March 2018. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoEditors' Note: Call for Articles on Firearm-Related Harm Metrics Cited bySocial risk behaviors for firearm violenceCounselor advocacy against gun violence: a systemic perspective with advocacy and wellness competenciesAssessing the contagiousness of mass shootings with nonparametric Hawkes processesAssociations of firearm dealer openings with firearm self-harm deaths and injuries: A differences-in-differences analysisAI applications in the business and administration of health careInformationPublic health champions in the making: An innovative undergraduate nursing pedagogyThe Firearms Data GapThe domestic violence fatality review clearinghouse: introduction to a new National Data System with a focus on firearmsGun Violence and Cardiovascular HealthA Letter From the PastEditors' Note: Call for Articles on Firearm-Related HarmThe EditorsInsights from population health science to inform research on firearms 19 June 2018Volume 168, Issue 12Page: 876-877KeywordsChildrenFire safetyFirearm injuriesGamesPrevention, policy, and public healthResearch fundingResearch reporting guidelinesSafetySuicideViolent crime ePublished: 20 March 2018 Issue Published: 19 June 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. 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