The recent attack at the Pulse nightclub in Orlando, Florida, in which 49 people lost their lives and dozens more sustained serious injuries, was greeted with shock, but also with an unsettling familiarity. Gun violence has inarguably become firmly entrenched in all corners of this country. Towns like Aurora, Newtown, and Columbine are now shorthand for the collective anguish that follows mass shootings, while large cities like Chicago deal with an equally insidious but less media-attended epidemic of daily firearm violence.
Doctors and nurses may be uniquely positioned to have an impact on combating this trend, involved as they are in the treatment of patients who have been or may become victims of gun violence. Here is an overview of the most pressing questions for these healthcare professionals.
Q1: What is the availability and impact of guns in the United States?
Approximately a third of people in the United Sates own a gun, although variations among the states are considerable, ranging from as low as 5% in Delaware to as high as nearly 62% in Alaska.
Figure 1. Percentage of homes with a gun, by region. Adapted from Pew Research Center (American Trends Panel; April 29-May 27, 2014).
In 2013, there were 33,636 firearm deaths, accounting for 70% of homicides and 51% of suicides.Every day in America, 297 people on average are shot and 89 die; among children and teenagers, there are 48 daily shootings and seven deaths.
Although mass shootings with assault rifles routinely spur national discussions about efforts to reduce gun violence, they account for only 2% of national gun homicides; handguns are the most frequent source of firearm deaths. This staggering epidemic is more fittingly attributed to situations like those currently plaguing Chicago, where there were nearly 3000 shooting victims in 2015 alone.
Q2: What does the research tell us about guns and health?
Research into gun violence has been substantially restricted in the United States by a now 20-year-old provision freezing funding to the Centers for Disease Control and Prevention (CDC) for activities that "may be used to advocate or promote gun control." The decision is linked to a campaign by the National Rifle Association (NRA), in reaction to a high-profile 1993 study that concluded that the risk for homicide was higher in households in which guns were kept. The American Medical Association recently called for lifting the funding ban.
States with tighter gun regulations experience comparatively fewer injuries and deaths from firearms, as well as less access by children. Another recent analysis predicted an 80% drop in firearm-related fatalitiesif all states adopted a strategy of prepurchase background checks and traceable bullets.
Proponents for further restrictions often cite the example of Australia, where the government reacted to a 1996 mass shooting by implementing a ban on assault rifles, increased registration requirements, and a large-scale buy-back program. A study in JAMA reported a dramatic decline in firearm deaths in the years since 1997, though larger trends prevented the authors from determining whether these governmental initiatives were responsible.
Q3: What is the position of professional associations regarding the role of clinicians in gun counseling?
Healthcare associations support their members taking an active role in gun violence prevention. For more than two decades, the American Academy of Pediatrics has had an official position statement advocating discussion with parents of the risks of gun access to children. More recently, in 2015, eight major medical societies published a statement in the Annals of Internal Medicine with recommendations to combat gun violence, including their opposition to laws preventing physicians from discussing a patient's gun ownership.
A Medscape reader poll on the question of whether healthcare workers should enter into gun counseling discussions found 47% favoring this approach and 39% opposing it. Previous articles on the topic have garnered a substantial reaction among our readers, who, like the general public, hold passionate points of view.
Q4: What does the law say about healthcare professionals' role in gun counselling?
Beginning in the early part of this decade, several states developed laws that prohibited healthcare professionals from asking patients about guns in their home or officially collecting such information, unless there was an explicit medical need for that information. The most prominent of these laws is Florida's Firearm Owner's Privacy Act, which has been opposed by physicians on First Amendment grounds and is currently being contested by the American Bar Association.
A recent review article affirmed that these bills have limited impact, given the room that physicians have to disclose relevant information about firearms to concerned people and groups, such as caregivers and law enforcement.
Bills that would put in place more rigorous restrictions on healthcare workers have been introduced in North Carolina and Ohio but so far have not been approved.
Q5: What can clinicians do now?
The number of gun-related deaths among children and adolescents makes pediatrics a promising field for addressing gun violence. Some have suggested that pediatricians offer in-office counseling on gun storage practices. The NRA offers the Eddie Eagle GunSafe® Program to inform children about gun safety. On the other end of the spectrum, physicians with geriatric patients should note the specific risks posed by gun ownership among those with dementia, and advise accordingly to diminish the threat.
More controversial is the physicians' role in identifying and reporting patients who own guns and suffer from potential mental illness. New regulations from the Department of Health and Human Services allow for state agencies responsible for declaring individuals incompetent or ordering them into mental institutions to inform the FBI's gun-check system. This would seem to be evolving, as mass shootings continue to entwine the issues of gun control and mental illness, however imperfect this pairing may be.