Gun Violence as a Public Health Issue

By Ajay K. Singh, MBBS, FRCP, MBA
November 21, 2017

An interesting viewpoint about gun violence was recently advanced by Nicholas Kristof (with Bill Marsh) in the New York Times.

Kristoff argues that a blanket opposition to guns hasn’t worked and that an alternative approach of regulating guns should be considered. He advocates a “public health approach.”

The article cites some staggering facts:

  1. Guns per 100 people—for the US, 88.8; the next closest Switzerland at 44.7; Canada comes in at 30.8 and Japan 0.6.
  2. Murders per 100,000 people—the US 3.0; the next closest Italy at 0.7; Canada comes in at 0.5.
  3. Research on guns: from 1974 through 2012, the NIH funded just three research awards.

The Kristof article makes some sensible recommendations that seem to resonate with Americans. Here are three that caught my eye:

  1. Background Checks—93% of Americans surveyed agree and yet 1 in 5 guns are obtained without one. Nearly 90% of Americans agree that the mentally ill shouldn’t be buying guns.
  2. Safe storage—making sure guns are inaccessible to children and have trigger locks.
  3. Banning under-21-year-olds from purchasing guns—we don’t let them drink, but allowing a teenager to buy a semi-automatic gun seems sensible?

Other ideas that we could consider with a public health approach include taking a systems approach. How can the health system help reduce gun violence?

  • Could the primary care doctor ask patients about gun ownership, and perhaps even counsel them about safe gun use?
  • Does integrating educating patients about safe storage and making sure guns can’t be fired accidentally seem to make a lot of sense?
  • Could research be funded that predicts which individuals are prone to gun violence? Perhaps, high-risk individuals could be screened and then offered help by the health system?
  • Could sensible controls be built-in that, on the one hand preserve privacy, but at the same time regulate access to guns in people with mental illness? Should people with personality disorders or a history of psychotic illness be allowed to buy guns without undergoing some secondary screening? On a related note, merging databases that screen people as a part of a “background check” with databases that record diagnoses around mental health could be developed.

Whether gun violence abates in the US is a complicated question. At one level, solutions are a function of societal trends, politics, and the power of the gun lobby. Still, thinking about novel ways to frame an important problem isn’t a bad idea. Gun violence kills people, and as Kristof suggests, emphasizing and framing it as a public health issue makes sense. Has anything else worked?


Learn more about Health and Health Care Disparities from a panel of HMS experts.


Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Share your thoughts on solving America’s gun violence crises in the comment section below.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Ending America’s Gun Violence

By Ajay K. Singh, MBBS, FRCP, MBA
November 7, 2017

…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries. – Faiz Gani

Gun violence is a leading cause of premature death in the US, killing approximately 30,000 people and causing about 60,000 injuries each year.

In the midst of writing an article about a blog post on gun violence by Faiz Gani, I heard breaking news about 26 people tragically killed in a Texas church.

Senator Chris Murphy (D-Conn) issued a statement after the Texas church mass shooting: “As my colleagues go to sleep tonight, they need to think about whether the political support of the gun industry is worth the blood that flows endlessly onto the floors of American churches, elementary schools, movie theaters, and city streets. Ask yourself—how can you claim that you respect human life while choosing fealty to weapons-makers over support for measures favored by the vast majority of your constituents.”

While the motive for the Texas mass shooting (or for that matter, the tragic mass shooting in Las Vegas) remains elusive, one factor that has been common among some earlier mass shootings is that the perpetrator(s) suffered from mental illness.

Besides the mental instability part of the problem, there is also the economic cost. The post by Faiz Gani in Health Affairs discusses the price of gun violence:

Thousands of individuals incur firearm-related injuries daily, leading to approximately 36,000 deaths each year from a firearm-related injury. The number of nonfatal injuries is estimated to be three times that number…we estimate that the annual financial burden associated with the ED and inpatient care for firearm-related injuries to be $2.8 billion in hospital charges. Taking into account the costs of rehabilitation, repeat admissions, and lost work, the CDC estimates that each year, approximately $46 billion are lost due to firearm-related injuries. This figure is comparable to the $49 billion spent to treat patients with chronic obstructive pulmonary disease, the third leading cause of death in the United States…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries.

Setting aside constitutional right issues around gun ownership and the huge and tragic human cost of gun violence, there is the economic cost. Isn’t it worth asking if better access to mental health services to perpetrator(s) would reduce the current rate and extent of mass shootings?

Gani’s post suggests that from a purely economic perspective, the government investing in more mental illness treatment (programs and facilities) might make the difference. Even if mental illness is not formally diagnosed, most of us would agree that this type of mindless, despicable violence has a component of mental instability.

Share your thoughts with Harvard Medical School in the comment section below.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Doctors, Patients, and Guns—Revisited

October 5, 2017

In light of the mass shooting that occurred earlier this week in Las Vegas, it seems prudent to update the information in the following previously published blog post, Doctors, Patients, and Guns, and re-open a discussion on whether or not doctors can impact gun deaths by identifying patients as gun owners.

In the February 7, 2017 post by Dr. Ajay Singh, Dr. Singh brought attention to a 2011 law passed in Florida that sought to prohibit health care providers from asking patients if they owned guns. Nicknamed the “docs vs glocks” law, it had been found unconstitutional for violating the 1st Amendment rights of doctors. That decision was subsequently vacated by the 11th US Circuit Court of Appeals, and a further appeal had yet to be ruled on.

On Feb. 17th, a week after the post was published, the full appellate court struck down the law, and the state did not file any further appeals. According to an article in the Palm Beach Post, Judge Adalberto Jordon wrote, “Florida may generally believe that doctors and medical professionals should not ask about, nor express views hostile to, firearm ownership, but it ‘may not burden the speech of others in order to tilt public debate in a preferred direction.’”

Now that Florida doctors are free once again to ask patients about gun ownership, the question remains as to whether or not this is a fair medical question or an invasion of privacy? In a 2016 post by Olga Khazan in The Atlantic, Khazan noted that while guns were used to kill people in about 250 justified shootings in 2014, they were used in over 21,000 suicides during that same time period, or by half of all Americans who committed suicide. She then continued:

Having a gun in the home is also strongly correlated with accidental shootings. As I’ve written, about 1.7 million children live in homes with guns that aren’t safely stored. Toddlers alone have shot at least 23 people this year.

Most unintentional shootings of children happen in homes where guns are legally owned, but not stored safely, and 70 percent of them could have been prevented if the gun had been stored safely.

Presumably then, the idea behind asking patients if they own guns is to follow up an affirmative answer with a conversation on safe gun storage, much like doctors discuss other health and safety issue with their patients such as wearing helmets or seat belts. It may also open up conversations about depression or other mental health issues.

Here is Dr. Singh’s original post. We hope that you will read it and share with us your opinions and/or experiences with this important issue.


 

By Ajay K. Singh, MBBS, FRCP, MBA
Tuesday, Febraury 7, 2017

A few months back when I saw my primary care physician at one of the Brigham and Women’s Hospital practices, I noticed that there was a question on the pre-visit questionnaire asking about whether I owned a gun. I do not own a gun and never have and so had no problem in answering no to this question.

Recently, however, I noticed an article in Kaiser Health News discussing whether physicians should be allowed under the law to ask about their patients’ gun ownership. Really? [continue reading…]

Doctors, Patients, and Guns

By Ajay K. Singh, MBBS, FRCP, MBA
Tuesday, Febraury 7, 2017

A few months back when I saw my primary care physician at one of the Brigham and Women’s Hospital practices, I noticed that there was a question on the pre-visit questionnaire asking about whether I owned a gun. I do not own a gun and never have and so had no problem in answering no to this question.

Recently, however, I noticed an article in Kaiser Health News discussing whether physicians should be allowed under the law to ask about their patients’ gun ownership. Really?

The article states: “Some states have imposed restrictions on gun-related information that patients must provide or that can be collected by providers and state officials. The most notable is Florida, which in 2011 passed the so-called ‘Docs vs. Glocks’ law that generally prohibited doctors from asking patients if they had a gun at home.

The law was found unconstitutional, then that decision was overturned by a divided three-judge panel of the 11th U.S. Circuit Court of Appeals in Atlanta. The full appeals court in turn vacated that decision and heard oral arguments last year, but has yet to rule. In the meantime, the Florida law has not gone into effect.”

So I dug into the literature a bit and came across a comprehensive article on the issue published back in August 2016 in the Annals of Internal Medicine by Wintemute and colleagues.

Some highlights:

  • In 2014, a total of 33,599 Americans died of gunshot wounds.
  • No federal or state statute prohibits physicians from asking about firearms when such information is relevant to the health of the patient or others.
  • When to ask? Firearm information would be directly relevant to the health of an individual patient and that patient’s close contacts under three general conditions:
  1. The first arises when a patient provides information or exhibits behavior suggesting an acutely increased risk for violence, such as explicit or implicit endorsement of suicidal or homicidal intent or ideation.
  2. The second involves patients who possess other individual-level risk factors for future violence. (A history of violence perpetration, patients hospitalized or treated in emergency departments for violent victimization, history of alcohol and/or drug abuse.)
  3. Third, questions about firearms would be relevant for patients in demographic groups that are at increased risk for firearm-related injury. Middle-aged and older white men are at high risk for firearm-related suicide (up to 5 times higher than black men of the same age), and young African-American men are 20 times as likely as young white men to die of firearm-related homicide. Children and adolescents may engage in risk behaviors with firearms because their judgment and cognitive skills are not fully developed.”

The article concludes: “Medical specialty societies recommend asking and counseling about firearms during routine patient care or as an element of risk assessment. Neither the law nor the Second Amendment prohibits such activities, and the First Amendment may protect them.

” Quae Sunt Quasi Quaedam Manifesta” (Latin for “Some things seemed obvious.”)

Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.