JAMA Network Open Editor Frederick Rivara, MD, MPH, discusses approaches to reducing firearm violence with several JAMA Viewpoint authors: Sandro Galea, MD, DrPH (Boston University), Elinore J. Kaufman, MD, MSHP (University of Pennsylvania), and Roger A. Mitchell Jr, MD (Howard University). Topics include the state-level response to firearm-related harms, the paucity of data on firearm violence, and the pervasive health effects of firearm violence on neighborhoods and in the carceral system.
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[Rivara] Over 48,000 people have died from firearm injuries in the United States in 2021, making it an extremely important public health problem. The United States is unique among high-income countries in allowing people to have firearms at home. In fact, we have 400 million firearms in U.S. homes in this country. This week, JAMA is publishing a series of Viewpoints on this topic. Today I'm joined by authors for three of these Viewpoints. Let me introduce them, and I'm sure we'll have a very interesting discussion. Dr Elinore Kaufman is an assistant professor of surgery, and a trauma surgeon at the University of Pennsylvania. She wrote a Viewpoint on the epidemiology of firearm injuries in the United States with Dr Kit Delgado, who's an emergency medicine physician, also at the University of Pennsylvania. Dr Roger Mitchell is chair of the Department of Pathology at Howard University College of Medicine. Before that, Dr Mitchell served as interim Deputy Mayor for Public Safety and Justice and [as] the chief medical examiner for the District of Columbia. He’s the author of a Viewpoint with Dr Jay Aronson, who is the founder and director of the Center for Human Rights Science at Carnegie Mellon University. Their Viewpoint is on violence in the carceral state. Finally, Dr Sandro Galea is a physician-epidemiologist, and dean of the School of Public Health at Boston University. He authored a viewpoint on state firearm laws and their effect on firearm injuries and death with Dr Salma Abdalla, a research fellow at his institution. So I thought we would start with the issue of data. Science depends upon the ability to determine who is injured, who has died, the circumstances of those injuries and deaths. To do this, we need data. It's an important topic with all of us, which all of us who have worked in this field of struggle and try to do the best we can with the available data that we have. Dr Kaufman. Why don't you start with talking with us about what you see are the biggest gaps we have related to firearm violence.
[Kaufman] Thank you so much for for the opportunity to contribute this Viewpoint and for the opportunity to be here in really all of your extremely esteemed company today. It's an honor and a humbling one. And, you know, it's as you just mentioned, you said injuries, deaths and the circumstances, and I would say that we do not have adequate data in any of those spheres when it comes to firearm injury. But I'll maybe start with the greatest gap which comes in nonfatal injuries. So we have decent data, I would say, on who dies from firearm injury. It's delayed, it's incomplete, it's imperfect. But we get it. We get it from the CDC and other sources eventually. We don't even really know how many people are shot on a given day, given week, given month in the United States. The best data I think that we have on that comes from probably health care sources related to emergency department visits. But they're delayed by years. They're incomplete. And some of the most essential information may be inaccurate when it comes to the intent of the injury, whether something was unintentional or intentional. And there's all kinds of things missing from that. It's partly my bias. I'm a trauma surgeon. I take care of those patients who have those nonfatal injuries. So they're important to me, but they're also important to all of us. These are the members of our communities whose lives are affected, and whose families are affected, and whose communities are affected and whose recoveries can be extremely challenging. So I care about it for those reasons, but I think we should all care about it for scientific reasons as well, because when we try to measure the impact of policies or programs that attempt to prevent injury, if the only outcome we can measure accurately is death, we're only looking at the tip of an iceberg. And our ability to detect change is going to be really limited when we can only see the most severe cases. Especially when it comes to some of the less lethal segments of this epidemic. Firearm suicide, e're going to see almost all we need to see in deaths, unfortunately, because it’s such a lethal means. But if we want to talk about reducing unintentional injuries, the vast majority of those are going to be non-fatal. And thankfully so. But how are we ever going to know if we're making a difference? So we really need those data on the nonfatal part of this epidemic.
[Rivara] Thank you. Dr Mitchell, you also bring up in your Viewpoint the fact that we don't really know how many people are injured and killed during interactions with the police or while incarcerated. Can you tell us from your experience what you've seen, and the problems that you've encountered?
[Mitchell] Thank you again for having me and being part of the writing of the Viewpoint and this podcast. The federal government has been attempting to capture data surrounding the people who are dying associated with the carceral system for years since 2000, but have been actually doing a poor job of collecting that data. There's a lot of jails and prisons in this country where we don't know how many people are dying, both from natural disease, as well as the injuries that we could see from non-natural phenomena as it relates to gun violence. Obviously, the gun violence that we see associated with law enforcement force happens in the pre-custody phase, but we don't even really know how many people are dying secondary to law enforcement force or gunshot wounds secondary to law enforcement and the criminal legal system. And right now, actually, the Bureau of Justice Statistics doesn't do a really good job at collecting the data that we have currently. So as we're looking at how we're responding to gun violence in this country, and we tend to lean on our law enforcement, we have to make sure that we understand what types of deaths, injuries, or subsequent diseases come from, even that interaction as well. And so it impacts Obviously I have a bias, I'm a forensic pathologist by training. And so ,starting with mortality, right,when we when we can know gives us a glimpse into that deeper iceberg, right? That we need to know. And so when we don't know how many people die, imagine what we don't know about how many people are injured or suffer.
[Rivara] Thank you. Dr Galea, your Viewpoint discusses using data to examine the effect of state laws, good or bad, [on] the epidemic of firearm violence. To do that, you and other investigators need data to tell us the big issues that you've encountered in trying to evaluate these laws.
[Galea] Yeah. First of all, thank you, Dr. Rivera, for having me on this podcast, and thank you for publishing the Viewpoint. In addition to what my colleagues have said, we have been limited in terms of federal funding being devoted to studying firearm, related violence. And that that goes back more than a quarter century. There was an amendment called the Dickey Amendment after Congressman Jay Dickey, who was behind it at the time, although he later changed his mind on it, that was appended to an omnibus spending bill which essentially prohibited the CDC from using federal funds for advocacy around minimizing gun violence. But that was interpreted as a broader... ban is a strong word. So it was interpreted as a broader prohibition on using any federal funds on gun violence research. So essentially there was no federal spending on gun violence research for about 25 years. In 2020, there was a $25 million addition to the budget, specifically for research. It was the first time in 25 years that we had any federal funds devoted to this topic. Without federal funds devoted to research, we simply don't advance our scholarship. And several foundations and private individuals have stepped in. Researchers have been creative in terms of being able to do research with relatively little money, but essentially there has been no infusion of resources studying this area. You know, the advances in medicine and health in the U.S. globally are directly linked to how much money we spend on that research. And we have spent, proportionately to the burden of morbidity and mortality, as both my colleagues mentioned, we have spent far less money than we should on this problem and as a result commensurately we know much less that.
[Rivara] Dr Mitchell, I thought that under President Obama there was going to be a change in reporting and recording of legal intervention deaths. Has it changed? What has happened with that?
[Mitchell] It made it officially law, right? So HR1447 requires us to report deaths in custody. And just for our listeners, deaths in custody is, is phases. It starts in the pre-arrest phase when you're when law enforcement becomes involved with someone, and then it carries all the way over into the jail phase or incarceration phase. And every step in between, you can have different causes and manners of death. But simply put, there lacks compliance and enforcement of the law, which is the Deaths in Custody Reporting Act. Now, many jails and prisons are not even federally reporting. Even though there's a mandate, there's no reporting or there's underreporting, let alone the suicides and homicides. We still see a stigma around those who are incarcerated. Those are “less than”. Why should we care about who's dying in the carceral system? They must have done something to get there, right? And so if a death occurs in the system, there's currently not that public outcry. And, you know, that's what we need. We need those in public health around, those of us that are physicians or researchers to want to know why people are dying from disease or injury no matter where they are. We have a great law that requires us to do so, but unfortunately is not being fully enforced.
[Rivara] Is that a federal issue in terms of the enforcement or a state issue?
[Mitchell] It's a federal issue. There are so many jails and prisons across this country. The federal agencies and the federal government is uniquely positioned to ensure that we gather this data. And there was just a Senate hearing yesterday in the permanent subcommittee of investigations in the Senate, led by Senator Ossoff out of Georgia, that that looked at this and really is calling for all hands on deck. And it goes to Dr Galea’s point is that if properly funded, right? It's not just the federal government that has to do this work, you know, academia and public health organizations, the AMA, the National Medical Association, can step in and help do some of this research and do some of this work.
[Rivara] Thank you. Dr Galea, one of the facts that you that is commonly brought up with talking about the effects of state laws is that we have porous borders between states. And in the absence of good national federal legislation, for example, for things like universal background checks, how effective can these state laws actually be?
[Galea] So there's no question that the porousness between states poses a problem how effective any state law can be. But it's also clear that state laws do make a difference. It's very clear that states that have laws that restrict guns from hands of children, through things like gun safety mechanisms, keeping guns away from people under 2,1 states with laws that keep guns away from people who have a history of violent offenses, states with laws like universal background checks. Those states have lower rates of gun violence, gun injury and gun deaths than other states. The porousness of borders clearly makes a difference, but even that is not enough to mitigate the influences of these laws. I think one of the key lessons, though, is that when you have things like the porousness of states and when you have so many handguns in the US- you know, we shouldn't forget that there’s roughly a handgun in the U.S. for one, for every citizen in this country- that doesn't mean every citizen has a handgun, but there’s roughly the same number
[Rivara] Including our children...
[Galea] Including our children, for sure...And it's concentrated in about 25% of Americans who actually own all the handguns. When you have so many handguns, any single state law by itself is not going to be all the difference. And what looking at state laws teaches you is that you need a combination of a number of laws that tackle the problem from multiple directions. You know, I live in Massachusetts, which is the state that consistently has had, in the contiguous U.S., the lowest rate of gun violence in the country. And that's not because Massachusetts has done any one thing, it's because of any number of things all together. So the the challenges are such that I think it's pretty clear that it requires a whole combination of state level regulations, policies, and implementation of those policies to make a difference.
[Rivara] And I think that's a really important point for our listeners. Well one of the issues that a number of you brought up in your viewpoints is the psychological toll that firearm violence has on families, schools, communities and nation as a whole. Do you think that's just been given enough attention, Dr. Kaufmann? Why don’t you start?
[Kaufman] No, that's an easy one. No, it absolutely isn't, I think. We don't pay enough attention to any aspect of this epidemic that we're talking about today. If we do pay attention, that's to the most shocking sets of deaths in public mass shootings. If we pay the next bit of attention, maybe it's the deaths from community violence, occasionally from suicide. We don't at all talk about what survivors struggle with and what the secondary victims, the co-victims struggle with, because our patients that we take care of who survive have rates of depression and PTSD that are on the order of what our military veterans experience, right around 50%. And it's not just those diagnosable conditions obviously. Firearms violence, particularly community firearm violence, is a structurally determined disease that is in large part, I believe, driven by decades and decades of structural racism and systematic disinvestment in neighborhoods of color. And therefore, our patients, before they're injured to begin with, are facing an enormous amount of disadvantage. They get shot, they return to the same environment that we, as a society, allowed to put them at risk to begin with. They're less equipped to thrive in that environment. And no, we don't pay enough attention to it. And unfortunately, as Dr. Mitchell said, I think as a society, I agree we don't care nearly enough about people who are incarcerated and we don't care nearly enough about the young Black men and boys who make up the majority of patients that I see as victims of community violence.
[Galea] And let me add one thing to that, if I may. I agree completely with everything Dr Kaufmann said, and actually echoing Dr Kaufman and also something Dr Mitchell said earlier, the paucity of data about the mental health consequences of firearm violence extends not only those who are victims of firearm violence, but to their families and their communities. There's evidence from other studies about other causes of trauma that would lead us to suspect that whole communities have their psychological health affected by the fact that there's a disproportionate concentration of people who are victims of firearm violence. But the data that show the mental health burden of this is really sparse and it reflects directly what I said earlier, which is the fact that we've actually had relatively little money devoted to research. So I tend to think and I published a little bit on this, that it’s a bit of a tip of the iceberg. We understand so very little about the full scale and psychological consequences of firearm violence.
[Mitchell] Dr Galea [and] Dr Kaufmann get it right. . And when you have a funding that is not representative of the burden of disease or injury and you're trying to understand it... Now I live in the community that individuals talk about. When I talk about community and how communities [are] affected by gun violence. I don't say “they”, I say “we” because I live in the same community that I serve here in Washington, D.C. And if we're really dedicated to making this a public health issue, then all the things that come along with treating a community after a disease outbreak has happened in community, from the needs- the social needs of a community, to the mental health needs of a community... We know as early as the early 1900s, when W.E.B. Du Bois talked about it- education, economics, housing, health care and criminal justice. Now environmental justice issues, disparity to access to those things is going to breed violence no matter where and no matter what race an individual or group of individuals are. And so we really have to level that playing field. We know that where we see homicidal violence, that playing field is not leveled because of institutional structural racism. But we also see this burden of disease, of suicide, of gun violence in communities. And so we have to talk about suicide or gun violence in the same terms, so that people understand that it's not them and us, it's we that are being affected. And quite frankly, suicidal gun violence is more pervasive and kills more people in this country than does homicidal gun violence. So we have to really buckle down and make this truly a public health concern.
[Rivara] I'm really glad that you brought up the issue of suicides, because in the United States as a whole, 60% of firearm deaths are suicides. As Dr Kaufmann says, 90% of those people die in the field. She doesn't see them at the trauma center, because they don't survive to make it to the trauma center. So those are really very important points.
[Galea] 60% of all gun deaths are suicide, or death by suicide. And one of the things I hear often as well, if we have fewer guns and people will use other means to commit suicide. But I think the point- Dr Kaufman made this point earlier in passing, so I just want to underscore it. The difference is the lethality of firearm-related suicide is so much higher than anything else. And the most common means of attempted suicide is drug overdoses. But the leathality of drug overdoses is 5 to 10%. The lethality of firearm-related suicide attempts is 90 plus percent. So there is no argument that the guns being widely available mean that death by suicide is much more likely when somebody tries to use a gun. And things are really important point that is, frankly, I feel lost in the public conversation.
[Kaufman] 90% of people who attempt suicide with a firearm will die on that first attempt. But the other 90% statistic is that 90% of people who attempt suicide in whatever way and survive, will not go on to die by suicide later. Suicidal impulses are very often fleeting. And so when people have such easy access to firearms, we are missing the opportunity to treat mental health. We are missing the opportunity to get people individuals and their families and their communities, second chances that they deserve the treatment they do deserve, the services they deserve. The substitution is not equal, and it means really do matter in suicide even more than in community violence.
[Rivara] Right. And as I was going to say, the whole topic of lethal means, safety, lethal means restrictions are really important because firearms are by far the most lethal means available. So let's finish up -I want to just each of you have one or 2 minutes, just talk about what do you think would be the one or two things would make a realistic difference in the topic you wrote about in your Viewpoint. Dr Kauffman?
[Kaufman] So as far as data availability, I'm going to stick with non-fatal injuries and say we have ample evidence- and this I think really is a federal government responsibility, maybe a state government responsibility. I think those researchers are limited in what we can do piecemeal. We have ample evidence from measles, from [unintelligible] and now ample evidence from COVID to say that if we want to know the incidence of a disease, if we want to know the hospitalizations of the disease, if we want to know the fatalities in real time on a daily basis, we can do that. So the CDC has a pilot program of emergency department surveillance for firearm injury. It's currently operational in about ten jurisdictions, and we should have that nationwide. It would expand our understanding enormously and our ability to respond enormously.
[Rivara] Thank you. Doctor Mitchell?
[Mitchell] Yes. You know, understanding gun violence from a public health issue and making sure that we focus in on the different ways of handling gun violence, from the smoldering gun violence in communities that are disenfranchised, and how you prevent those gun violence deaths, are different than the gun violence deaths to be prevented by suicide. It's really being clear that we're to use a scalpel in understanding gun violence prevention. But as it relates to deaths in custody, the public health community is abdicating our responsibility by allowing the criminal justice community to be the counters of deaths in custody. You need a checkbox on the U.S. standard death certificate. Checkbox, we know how many people are dying from maternal mortality-related issues, how many people dying from pedestrians struck or motor vehicle collisions. How many people are dying associated with smoking? Those are all checkboxes on the US standard death certificate. We need a ‘deaths in custody’ checkbox in the US. standard death certificate. Very easy, very simple. And then once compliant, then we build out a whole community of researchers that are looking at every single cause and manner of death as it relates to deaths in custody, every single jurisdiction. We can build a whole research portfolio on understanding deaths in custody and the circumstances before and after the carceral system if we have a checkbox on the U.S. standard death certificate. So I think as public health providers are, we should advocate for that and the CDC can do it today. It's not something that legislation needs to do.
[Rivara] It seems like a sort of a free, easy thing to do if we can have the will to do it. Dr Galea, a final word?
[Galea] Yeah, you know, we're at a really important moment in the journey to try to mitigate firearm violence in this country. I think there's momentum behind activism like we haven't seen before. I think the momentum behind the activism in many respects has outstripped our evidence because we have not invested in the data to show what works and what combination most effectively. I think we know enough to know that certain levels of things work at the state level. We know enough to know it's a combination of things that work at the state level. But I think the more we can provide the evidence about the combinations of approaches that will serve to reduce injury, fatal injury, nonfatal injury from firearms, firearm death by suicide, death by homicide, I think it can combine with the activist energy we have right now in activist, I mean, in the sense of moving towards change- and actually save thousands of lives. I mean, as you said, that 48,000 people a year, I think people who offer sober assessments of this think that we can reduce that by half in terms of number of deaths per year through things that we already know work. That's a lot of lives saved and for every life saved, we’re probably dealing with two or three nonfatal injuries which have, as Dr Kaufman said earlier, longstanding medical and psychological implications. So there's a lot that can be done. And I think with a bit more push on data to document what can be done most effectively, we can be at a tipping point in this issue in this country.
[Rivara] Thank you all so much for these three wonderful Viewpoints you've written for participating in this podcast today. Thank you.
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