Health Professionals, Violence, and Social Change
Authors: Garen Wintemute
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions1 December 2020Health Professionals, Violence, and Social ChangeFREEGaren Wintemute, MD, MPHGaren Wintemute, MD, MPHUniversity of California, Davis, Davis, California (G.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-4411 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail “If it's not a health problem, then why are all those people dying from it?” Dr. David Satcher gave that quote about violence to The New York Times nearly 30 years ago, just after he took over as director of the Centers for Disease Control and Prevention.What is sometimes called the public health approach to violence is a relatively recent development. It requires a fundamental rethinking of our relationship to violence—for all of us as a society and for each of us as individuals. It means understanding that violence is not someone else's problem. Whoever we are, it's our problem.It also requires a rethinking of what violence is. Narrowly construed, violence involves physical force and death or injury, which can be physical or psychological. Many argue (as I do) that there is also structural violence, where political or economic power stands in for physical force and the adverse outcomes are disparities in health, life expectancy, and a broad array of social and economic conditions (1). The structures by which those disparities are produced have been built consciously and with a purpose. Most of us have contributed, knowingly or otherwise, to keeping those structures intact.Let's return to “all those people” Dr. Satcher had in mind. America has lost more civilians just to firearm violence in the past 10 years than we had combat fatalities in World War II. (I include homicide and suicide here. Both are intentional, and a bullet doesn't care whose finger is on the trigger.) At 2018 rates, in the next 11 years we could fill a second Arlington National Cemetery to the current capacity of the one we have, with civilians who die of gunshot wounds.It doesn't have to be this way—a simple fact that should make us angry and hopeful all at once. With motor vehicle–related deaths and injuries, for example, America mobilized. We put smart people on the case, charging them to study the problem and make recommendations for change. Policymakers acted on those recommendations, and the result has been a largely downward trend ever since (Figure, top).Figure. Firearm violence in the United States.Top. Deaths from motor vehicle injuries and firearm violence, 1950–2018. Bottom. Firearm homicide rates among males in the United States, 2018, by race/ethnicity. Data from reference 3. Download figure Download PowerPoint With firearm violence, we have taken the opposite approach. Over and over, in Washington and across most of the United States, we have deliberately turned our backs on the problem. The result: Trend lines for motor vehicle and firearm deaths have intersected.Now the coronavirus pandemic is driving an increase in violence, particularly firearm violence (2). That violence, like the pandemic itself, is shining a powerful spotlight on stark disparities and lethal abuses of power that threaten our existence as a free society.For compelling reasons, we are now focused sharply on disparities in the risk for violence by race and ethnicity. Our focus is first on individual tragedies—most recently, the killings of Rayshard Brooks, George Floyd, Breonna Taylor, Ahmaud Arbery, and others. Lift our gaze, and we see Stephon Clark, Hadiya Pendleton, Eric Garner, Freddie Gray, Michael Brown, Trayvon Martin. We see as well the broader catastrophe those killings represent. Homicide rates in 2018 among adolescents and young adult men (those aged 15 to 29 years), who are at greatest risk, were 81.7 per 100 000 persons for Blacks, 16.2 per 100 000 persons for Hispanics, and 5.4 per 100 000 persons for Whites. The rate ratio for Blacks and Whites was greater than 15:1, and 90% of those deaths involved firearms (Figure, bottom) (3).At the same time, we remember that violence and disparity travel together along all the other axes on which disparities exist. Gender and gender identification. Sexual orientation. Disability. Religion. National origin. Social class. Age. People are being killed in our country for occupying what someone else believes is the wrong position on each of those axes. We are one shooting—let alone one mass shooting—away from confronting again the tragedies that follow when hatred and difference collide.Health professionals are not-on-the-sidelines people. We work in the moment without losing the long view. Many of us understand violence broadly and are committed to action based on that understanding. The following are things you can do to be part of the solution, and Annals hosts a website (4) where you can make a public commitment to do them:1.Prevent as well as treat, because we have important information and guidance to provide and patients want to hear from us (5). Points of emphasis should include risks associated with having a firearm in the home (6), safer storage, and access reduction during times of crisis.2.Do research, because good science is a way of bearing witness—telling of things as they are—and because knowledge is power. Priorities for study include the socioeconomic factors associated with an increased risk for violence, the consequences of victimization, and the effectiveness of prevention efforts.3.Develop prevention policies, because sometimes the whole community is our patient. Evidence supports restrictions on access to firearms for persons convicted of crimes involving violence (7) and alcohol misuse (8) and the licensing of firearm purchasers (9). “Stand your ground” laws have been associated with an increase in homicide and should be repealed (10).4.Communicate, because we are leaders whose credibility arises from our commitment to service. How Americans talk about violence shapes how they think about it, and that determines what they do about it.5.Educate and train our colleagues, because lasting change is required and we are just getting started.Many of us have personal work to do as well, answering questions that we have been avoiding for years. What do I know about disparities and violence? How am I part of the problem? How can I become part of the solution? How can I help others to do the same?For the first time, violence is seen as a health problem that affects everyone, and that perception is increasing. There is a growing demand for action, based on sound scientific evidence, to save lives and restore communities to health. Our job is to act across the full range of our capacities to make those goals a reality. Such work in the present moment is how we honor the past and pay our debt to the future.References1. Farmer P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Univ of California Pr; 2004. Google Scholar2. Schleimer JP, McCort CD, Pear VA, et al. Firearm purchasing and firearm violence in the first months of the coronavirus pandemic in the United States. medRxiv. Preprint posted online 11 July 2020. doi:10.1101/2020.07.02.20145508 Google Scholar3. Centers for Disease Control and Prevention. WISQARS—Web-based Injury Statistics Query and Reporting System. Accessed at www.cdc.gov/injury/wisqars/index.html on 6 March 2020. Google Scholar4. My commitment to discussing firearm safety with at-risk patients. Annals of Internal Medicine. Accessed at http://go.annals.org/commit-now on 19 October 2017. Google Scholar5. Pallin R, Spitzer SA, Ranney ML, et al. Preventing firearm-related death and injury. Ann Intern Med. 2019;170:ITC81-ITC96. doi:10.7326/AITC201906040 LinkGoogle Scholar6. Studdert DM, Zhang Y, Swanson SA, et al. Handgun ownership and suicide in California. N Engl J Med. 2020;382:2220-2229. [PMID: 32492303] doi:10.1056/NEJMsa1916744 CrossrefMedlineGoogle Scholar7. Wintemute GJ, Wright MA, Drake CM, et al. Subsequent criminal activity among violent misdemeanants who seek to purchase handguns: risk factors and effectiveness of denying handgun purchase. JAMA. 2001;285:1019-26. [PMID: 11209172] CrossrefMedlineGoogle Scholar8. Kagawa RMC, Stewart S, Wright MA, et al. Association of prior convictions for driving under the influence with risk of subsequent arrest for violent crimes among handgun purchasers. JAMA Intern Med. 2019. [PMID: 31566654] doi:10.1001/jamainternmed.2019.4491 CrossrefMedlineGoogle Scholar9. Rudolph KE, Stuart EA, Vernick JS, et al. Association between Connecticut's permit-to-purchase handgun law and homicides. Am J Public Health. 2015;105:e49-54. [PMID: 26066959] doi:10.2105/AJPH.2015.302703 CrossrefMedlineGoogle Scholar10. Degli Esposti M, Wiebe DJ, Gravel J, et al. Increasing adolescent firearm homicides and racial disparities following Florida's ‘Stand Your Ground' self-defence law. Inj Prev. 2020;26:187-190. [PMID: 31862777] doi:10.1136/injuryprev-2019-043530 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: University of California, Davis, Davis, California (G.W.)Financial Support: This work was supported in part by grants from The California Wellness Foundation and the Heising-Simons Foundation and by the University of California Firearm Violence Research Center.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-4411.Corresponding Author: Garen Wintemute, MD, MPH, Department of Emergency Medicine, University of California, Davis, 2315 Stockton Boulevard, Sacramento, CA 95817; e-mail, [email protected]edu.Author Contributions: Conception and design: G. Wintemute.Drafting of the article: G. Wintemute.Final approval of the article: G. Wintemute.Obtaining of funding: G. Wintemute.This article was published at Annals.org on 4 August 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 December 2020Volume 173, Issue 11Page: 922-923KeywordsDisclosureFirearm injuriesHealth economicsHomicidePerceptionPrevention, policy, and public healthRacial and ethnic issuesSexual identitySuicideYoung adults ePublished: 4 August 2020 Issue Published: 1 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...