Gun Violence: A Public Health Problem with Evidence-Based Solutions

By Rachel Clingenpeel, MD
Assistant Professor, UAMS
Center for Children at Risk/
Arkansas Children’s House

Rachel Clingenpeel, MD
Assistant Professor, UAMS
Center for Children at Risk/Arkansas Children’s House

Within the past few weeks, two 4-year-old boys have shot and killed themselves while playing with unsecured guns in their homes. One of these, in Texas, was a stolen weapon; the other, in Michigan, was legally owned, and the child was the son of a law enforcement officer. Two young boys were shot to death in Connecticut by their mentally ill grandmother. Here in Arkansas, a 1-year-old girl was shot to death during an apparent domestic assault. 

These are but a few examples of recent gun-related child fatalities. The 2012 mass shooting in Newtown was an unfathomable horror that provoked deep emotions and a renewed national conversation about U.S. gun violence. However, victims of mass shootings represent a tiny fraction of the more than 30,000 Americans killed by guns each year, and the discussion must move beyond mass shootings to the larger question of how to reduce firearm-related morbidity and mortality. Those of us who spend our professional lives caring for the health of children may feel a particular urge to participate in the conversation. However, we may struggle to find the best way to do so, given the strong emotions surrounding these deaths, and the fraught politics surrounding guns in America. Health care providers can find a way forward by approaching gun violence as not a political issue, but a public health problem.

The public health approach to gun violence has many strengths. It involves the application of empirical methods to the exceedingly complex problem of gun violence, supplying data on which to base decisions, rather than solely emotions. Importantly, the public health approach to gun violence professes no interest in curtailing the safe and responsible activities of legal gun owners. The focus is not on gun ownership, but safety; like automobiles, guns are products that are commonly used, but should be subject to reasonable safety regulations. The questions asked via this method focus on how best to prevent the senseless and needless deaths and injuries that we all abhor.

Research has provided us with empirical support for a number of potential changes which, if enacted, could have a substantial positive impact on gun-related child morbidity and mortality.  These are endorsed by the American Academy of Pediatrics (AAP). As professionals who care for the health and safety of children, we can play a valuable role in advocating for these measures.

Implement universal background checks.
Federal law prohibits gun purchase or possession by individuals with a gun-disqualifying criminal or mental health history. However, more than 40% of U.S. gun purchases are so-called private sales with no background check performed; the lawfulness of these gun purchases is therefore not evaluated. Universal background checks would enable enforcement of existing laws regarding who may purchase guns and would improve efforts to keep guns out of the hands of people with an increased risk of violence. According to recent polls, the vast majority of Americans, including the majority of gun owners, support such a measure.

Advocate for improved access to mental health care and for the freedom of physicians to inquire about guns in patients’ homes as part of safety assessment.
The vast majority of gun homicides are not committed by people with diagnosed mental disorders, and even most mass shootings are committed by people who would not be prohibited from owning weapons by existing mental health criteria. The most common intersection between mental illness and gun violence is suicide, which accounts for approximately 60% of American gun deaths. Making mental health care more accessible, particularly among vulnerable populations, would be one potential avenue to reducing this toll. Gun availability greatly increases the lethality of suicide attempts, particularly among teenagers, for whom these attempts can be impulsive and for whom the permanence of the consequences may not be salient. It is important for physicians to discuss guns with parents while assessing the safety of children’s homes, particularly if there are persons in the household with depression or other mental health concerns. There have been attempts in some states to restrict physicians’ right to ask about firearms during medical visits, but we must oppose these restrictions on our practice of preventive medicine.

Require safe storage of firearms and ammunition. Enact child access prevention (CAP) laws.
The safest home for a child is a home without guns. However, if guns are present in a home, they must be stored safely. A randomized controlled trial showed that brief physician counseling combined with gun lock distribution improved self-reported rates of gun lock use. Another study showed that a safe storage campaign coupled with gun safe distribution reduced exposure to unlocked and loaded guns. Child access prevention (CAP) laws hold gun owners responsible if children gain access to and use guns that are not safely stored. Research shows that these laws are effective in reducing accidental shootings of children and are associated with lower rates of adolescent suicides.

Gun avoidance programs targeting children have been touted as an alternate way to reduce child firearm injury and death. It is argued that there is no need to lock guns away, if children have simply been taught to avoid them. However, research has demonstrated that the lessons of these programs are not applied by children when they are placed in a realistic simulation of encountering a gun. Children’s natural curiosity, impulsivity, and difficulty anticipating consequences are high hurdles to clear in keeping them safe from firearm injury, and this burden must lie with the adults in their lives.

Advocate for safer gun technologies.
Technologies exist to make guns personalized or “smart,” so that they can only be fired by an authorized user or users. These technologies have great potential to reduce accidental shootings of and by children, adolescent suicides, and crime using stolen guns. These technologies are not hypothetical; they are available and could be brought into widespread use with application of proper market and legislative forces. 

Oppose legislative restrictions on gun violence research.
The best way to discover how to reduce gun-related morbidity and mortality is through research. Unfortunately, federal regulations currently prohibit the release of data from the Bureau of Alcohol, Tobacco, and Firearms to the public, including researchers, as well as restrict funding for gun violence injury prevention research. There are many health professionals across the country eager to study how to prevent senseless tragedies like Newtown, and like the smaller-scale tragedies, too quickly forgotten, that occur in our country every day. We must let them.

Suggested Reading:
AAP Council on Injury, Violence, and Poison Prevention Executive Committee.  Firearm-Related Injuries Affecting the Pediatric Population.  Pediatrics 2012; 130 (5):  e1416-e1423
Webster, Daniel W and Vernick, Jon S.  Reducing Gun Violence in America.  Baltimore:  The Johns Hopkins University Press, 2013