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Treating Gun Violence with a Public Health Approach

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      On December 20, 2019, the Trump administration approved a fiscal 2020 spending agreement that will allocate 25 million dollars to the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health for research on gun violence. This agreement ends an effective ban on federal funding of gun violence research in place since 1996, and represents an important opportunity to depoliticize the gun violence epidemic by using a public health approach.

      State of Research on Gun Violence

      Efforts to study gun violence have been stymied for over 2 decades by a provision in Congressional appropriation bills known as the Dickey Amendment. Although the amendment does not explicitly prohibit federal funding of firearm research, it forbids the CDC from using “funds made available for injury prevention and control … to advocate or promote gun control.”
      United States Congress
      H.R. 2610 – Omnibus Consolidated Appropriations Act, 1997.
      The amendment was introduced largely in response to lobbying by the National Rifle Association following the release of a CDC study that found an increased risk of gun homicide in gun-owning households.
      • Rostron A
      The Dickey Amendment on federal funding for research on gun violence: a legal dissection.
      Since then, the debate on firearm research has centered on the contention that research would be used to justify gun control.
      As a result, there has been a marked reduction in gun violence research: between 1998 and 2012, there was a 96% reduction on federal spending on firearm injury research and a 64% decrease in the number of publications on this topic.
      • Alcorn T
      Trends in research publications about gun violence in the United States, 1960 to 2014.
      The National Academies of Sciences Engineering and Medicine has stated that “the scarcity of research on firearm-related violence limits policy makers’ ability to propose evidence-based policies that reduce injuries and deaths and maximize safety while recognizing Second Amendment rights.”
      The National Academies of Sciences Engineering and Medicine
      At the same time, gun violence has become increasingly widespread in the United States. On average, 100 people are killed by guns every day, and 100,000 Americans are wounded by firearms each year.

      Giffords Law Center. Gun violence statistics. Available at:https://lawcenter.giffords.org/facts/gun-violence-statistics/. Accessed February 17, 2020.

      The majority of gun deaths take place as a result of suicide, with other common causes including homicides, law enforcement shootings, and unintentional shootings.
      Although leading health care organizations have recognized gun violence to be a public health crisis, debates about firearm safety have been heavily politicized and focused on competing perspectives on gun ownership. The repeal of the ban on federal research funding is a promising opportunity to reframe gun violence through a broader lens of harm reduction and to implement evidence-based interventions.

      The Public Health Model of Injury Prevention

      The public health approach to injury prevention has been effective in mitigating harm from other causes of injury. This framework was adopted by Dr. William Haddon, an epidemiologist and public health physician who served as the inaugural director of the National Highway Traffic Safety Administration. Haddon proposed that “accidents” are studied using an “etiologic” framework rather than a lens of negligence or personal misfortune. He analyzed injuries at all stages, based on the injured person, the cause of the injury, and the physical and social context in which the injury occurred.
      • Waller PF
      Challenges in motor vehicle safety.
      This approach represented a groundbreaking move to understand the larger personal, societal, and environmental contexts of motor vehicle injuries. Based on this framework, the National Highway Traffic Safety Administration established 2 federal databases that examined outcomes of vehicle crashes, ranging from property damage and injury to death. Congress also approved funding for a CDC research program as well as initiatives by state and local health departments aimed at preventing motor vehicle injury.
      • Waller PF
      Challenges in motor vehicle safety.
      The results of this research led to policy change including the creation of the Federal Motor Vehicle Safety Standards, which regulates vehicles, drivers, and roadways. Improvements to vehicle structure included head restraints to prevent whiplash injuries, air bags, and side door beams, while roadway improvements included road illumination, guardrails, and work-zone safety measures. A particularly notable innovation was the seat belt, which reduces the risk of fatality for front-seat occupants in passenger cars by 45%.
      • Waller PF
      Challenges in motor vehicle safety.
      Notably, research on motor vehicle accidents did not result in a decrease in usage, and on the contrary, the number of motor vehicles in the country increased 11-fold from 1925 to 1999.
      Centers for Disease Control and Prevention
      Achievements in public health, 1900-1999 motor-vehicle safety: a 20th century public health achievement.
      The public health model of injury prevention has also been used to study and reduce unintentional drowning. The Consumer Product Safety Commission attributed dozens of drownings to circulation entrapments in pools, spas, and whirlpool bathtubs.

      Consumer Product Safety Commission. 1999-2011 Reported circulation/suction entrapments associated with pools, spas, and whirlpool bathtubs, 2012 report. Available at:https://www.cpsc.gov/s3fs-public/pdfs/entrap12.pdf. Accessed February 17, 2020.

      Similar data were key to legislative efforts requiring all pools to install drain covers. Additional evidence-based interventions include life jacket use, barrier installation, and supervision of young children. Collectively, these interventions have contributed to a 46% decrease in drowning fatality for infants under age 1 year, and a 28% overall decrease among children of all ages.
      Safe Kids Worldwide
      2018 Hidden hazards: an exploration of open water drowning and risks for kids.

      Applying the Public Health Model to Gun Violence

      As with motor vehicle accidents and drowning, a public health approach to injury prevention can reframe firearm violence as a societal issue, rather than an individual one. This model acknowledges the intersections of gun violence with populations and their environment. The new funding for firearm research can be targeted to answer important questions about safe gun storage and disposal and the effectiveness of interventions such as background checks, “smart guns,” and age limits for firearm access. Other unanswered questions that directly pertain to medical providers include best practices for patient counseling on gun safety and the intersection of gun violence with behavioral health issues. These data can guide policies governing firearm use as well as interventions to address the personal and environmental factors that contribute to violence. They can also inform standards implemented across health care settings, including those related to the care of patients who are at risk of committing or being subject to gun violence.
      In addition to guiding policy, government funding of firearm research also presents an opportunity to depoliticize the contentious issue of gun violence. As a former chief lobbyist of the National Rifle Association stated, a primary concern about this research was that it would depict “gun ownership [as] a disease that needed to be eradicated.” These concerns about the use of research to promote political agendas misconstrue the scientific approach to data collection. As scientists have long embraced for other fields, research on gun violence should not be understood as prematurely supportive of any one policy action; rather, data provide the context needed to inform policy. The CDC and National Institutes of Health can ensure that new funds for firearm research are used to broaden the scope of possible solutions and to inform a harm-reduction approach involving safety standards for continued firearm ownership. To this end, recipients of federal funding can also ensure that the process of grantmaking and funding allocation reflects the public health priority of objective data collection and remains insulated from political bias. Health professionals can play a critical role in this effort by emphasizing the scientific approach, orienting discussions of gun violence toward a goal of restoring data to policy, and using past instances of successful injury and mortality reduction to guide the response to the gun violence crisis.
      Gun violence is personal and its impacts are individualized. However, like with past public health crises, gun violence can be effectively treated using a scientific approach. Allowing government funding of research on gun violence is just one stepping stone to a national solution, but it is a significant achievement in reframing gun violence as the public health problem that it is.

      References

        • United States Congress
        H.R. 2610 – Omnibus Consolidated Appropriations Act, 1997.
        1996 (Available at:)
        • Rostron A
        The Dickey Amendment on federal funding for research on gun violence: a legal dissection.
        Am J Public Health. 2018; 108: 865-867
        • Alcorn T
        Trends in research publications about gun violence in the United States, 1960 to 2014.
        JAMA Intern Med. 2017; 177: 124-126
        • The National Academies of Sciences Engineering and Medicine
        Priorities for Research to Reduce the Threat of Firearm-Related Violence. The National Academies Press, Washington, DC2013
      1. Giffords Law Center. Gun violence statistics. Available at:https://lawcenter.giffords.org/facts/gun-violence-statistics/. Accessed February 17, 2020.

        • Waller PF
        Challenges in motor vehicle safety.
        Annu Rev Public Health. 2002; 23: 93-113
        • Centers for Disease Control and Prevention
        Achievements in public health, 1900-1999 motor-vehicle safety: a 20th century public health achievement.
        MMWR Weekly. 1999; 48 (Available at:): 369-374
      2. Consumer Product Safety Commission. 1999-2011 Reported circulation/suction entrapments associated with pools, spas, and whirlpool bathtubs, 2012 report. Available at:https://www.cpsc.gov/s3fs-public/pdfs/entrap12.pdf. Accessed February 17, 2020.

        • Safe Kids Worldwide
        2018 Hidden hazards: an exploration of open water drowning and risks for kids.
        2018 (MayAvailable at:)