A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation


– Dig deeper in defining mass firearms killings as a public health issue.

– Profile hospital Rapid Response preparedness for receiving injured from a mass shooting.

– How can hospitals prepare for an “active shooter” situation in the hospital?

“Shortly after the November 2018 publication of the American College of Physicians’ policy position paper on reducing firearm injury and death (1), the National Rifle Association tweeted: Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves…

In 2015, several of our organizations joined the American Bar Association in a call to action to address firearm injury as a public health threat. This effort was subsequently endorsed by 52 organizations representing clinicians, consumers, families of firearm injury victims, researchers, public health professionals, and other health advocates (2). Four years later, firearm-related injury remains a problem of epidemic proportions in the United States, demanding immediate and sustained intervention. Since the 2015 call to action, there have been 18 firearm-related mass murders with 4 or more deaths in the United States, claiming a total of 288 lives and injuring 703 more (3).

With nearly 40 000 firearm-related deaths in 2017, the United States has reached a 20-year high according to the Centers for Disease Control and Prevention (CDC) (4). We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731 000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths. The authors represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, American Medical Association, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, joins these 6 physician organizations to articulate the principles and recommendations summarized herein. These recommendations stem largely from the individual positions previously approved by our organizations and ongoing collaborative discussion among our leaders (1, 5–10)…

Our organizations support a multifaceted public health approach to prevention of firearm injury and death similar to approaches that have successfully reduced the ill effects of tobacco use, motor vehicle accidents, and unintentional poisoning. While we recognize the significant political and philosophical differences about firearm ownership and regulation in the United States, we are committed to reaching out to bridge these differences to improve the health and safety of our patients, their families, and communities, while respecting the U.S. Constitution.

A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation consistent with the U.S. Constitution. Efforts to reduce firearm-related injury and death should focus on identifying individuals at heightened risk for violent acts against themselves or others (20). All health professionals should be trained to assess and respond to those individuals who may be at heightened risk of harming themselves or others.

Screening, diagnosis, and access to treatment for individuals with mental health and substance use disorders is critical, along with efforts to reduce the stigma of seeking this mental health care. While most individuals with mental health disorders do not pose a risk for harm to themselves or others (21), improved identification and access to care for persons with mental health disorders may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

In February 2019, 44 major medical and injury prevention organizations and the American Bar Association participated in a Medical Summit on Firearm Injury Prevention. This meeting focused on building consensus on the public health approach to this issue, highlighting the need for research, and developing injury prevention initiatives that the medical community could implement (22). Here we highlight specific policy recommendations that our 7 organizations believe can reduce firearm-related injury and death in the United States.

Background Checks for Firearm Purchases; Need for Research on Firearm Injury and Death; Intimate Partner Violence; Safe Storage of Firearms; Mental Health; Extreme Risk Protection Orders; Physician Counseling of Patients and “Gag Laws”; Firearms With Features Designed to Increase Their Rapid and Extended Killing Capacity” (A)

“There were three high-profile shootings across the country in one week: The shooting in Gilroy, Calif., on July 28, and then the back-to-back shootings in El Paso, Texas, and Dayton, Ohio, this past weekend.

That’s no surprise, say scientists who study mass shootings. Research shows that these incidents usually occur in clusters and tend to be contagious. Intensive media coverage seems to drive the contagion, the researchers say.

Back in 2014 and 2015, researchers at Arizona State University analyzed data on cases of mass violence. They included USA Today’s data on mass killings (defined as four or more people killed using any means, including guns) from 2006 to 2013, data on school shootings between 1998 and 2013, and mass shootings (defined as incidents in which three people were shot, not necessarily killed) between 2005 and 2013 collected by the Brady Campaign to Prevent Gun Violence.

The lead researcher, Sherry Towers, a faculty research associate at Arizona State University, had spent most of her career modeling the spread of infectious diseases — like Ebola, influenza and sexually transmitted diseases. She wanted to know whether cases of mass violence spread contagiously, like in a disease outbreak.

“What we found was that for the mass killings — so these are high-profile mass killings where there’s at least four people killed — there was significant evidence of contagion,” says Towers. “We also found significant evidence of contagion in the school shootings.”

In other words, school shootings and other shootings with four or more deaths spread like a contagion — each shooting tends to spark more shootings…

Peterson and other researchers who study mass shootings think the media should avoid showing the shooters’ images and dwelling on their life histories and motives. “The fact that we give them that notoriety is problematic,” says Peterson.” (B)

“The country is splitting into the gun law-haves, and the gun law have-nots, and deadly statistics are now revealing the impact those policy decisions have on people’s lives.

It happened again. This time, gunmen in El Paso, Texas, and Dayton, Ohio, murdered 31 people and injured at least 50 more in separate mass shooting attacks within 13 hours of each other Saturday night and Sunday morning. It was, in many ways, just another weekend in America, the only nation in the developed world where horrific gun massacres regularly occur. Though nothing new, the frequency of such public mass shootings appears to have accelerated over the past five years, along with larger and more tragic death tolls. According to one recent analysis by The Washington Post, a mass shooting event has claimed the lives of four or more people every 47 days since June 2015. In the mid-’90s, such attacks happened just twice a year, on average.

But this surge in public executions has not swept across all corners of the country equally. Hawaii, for instance, hasn’t seen a mass shooting since 1999. Florida, on the other hand, has had six such incidents, defined by the US government as four or more people killed by a single individual, in the past three years alone, according to data from the nonprofit Gun Violence Archive. And like other forms of gun violence—including homicide, suicide, and unintended accidents—researchers are finding that mass shooting events happen more often in states with looser gun laws.

Because while Congress may not have passed any national gun laws in the aftermath of past mass shootings, individual state legislatures have. And as the disparity between states with weak gun laws and those with tough ones has widened, so too has the gap in mass shootings. Which means that terrorist acts like those committed in El Paso and Dayton over the weekend are more likely to keep happening to people who live in places where it’s easy to buy, sell, and carry guns. The country is splitting into the gun law haves and the gun law have-nots, and deadly statistics are now revealing the impact those policy decisions have on people’s lives.

Studying mass shootings, which make up only a tiny fraction of all gun deaths, has long been tricky, because of their historical rarity and a general dearth of data on guns or gun deaths. (That’s because of research-stifling federal legislation that was only recently overturned.) But one ironic effect of there being more mass shootings lately is scientists now have enough data to start to see trends emerging…

What the researchers found was that over time states have dug themselves into a bimodal distribution. That is, they’ve self-clumped into two distinct groups—a smaller one made up of eight states scoring between 5 and 25, and another, much larger, one clustered around scores from 70 to 100. “One of the most interesting things about this data is that we aren’t seeing a full spectrum, because there just aren’t that many states directly in the middle,” says Paul Reeping, the study’s lead author.” (C)

“…Two policies exist today that if properly designed, widely enacted, and adequately implemented would likely have saved these lives and could potentially save many more in the future. Their benefits would extend far beyond reducing the incidence of mass shootings (see map and the interactive graphic, available at NEJM.org).

The better known of these policies is the requirement that firearm sales involve background checks on purchasers. Background-check policies work at the population level to prevent firearm purchases by felons, people convicted of certain violent misdemeanors, and others who are at increased risk for violent behavior (specifics vary from state to state). Using background checks to prevent such persons from acquiring firearms is associated with a reduction of at least 25% in their incidence of arrest for a firearm-related or other violent crime.1

The second policy that could prevent firearm-related deaths is to allow courts to have firearms removed temporarily from people who pose an imminent hazard to others or themselves but are not members of a prohibited class. Again, provisions vary; in California, family members and law-enforcement officials can follow procedures based on those established for domestic violence to petition for a firearm to be removed. Physicians can play an important role in these cases by notifying eligible petitioners when intervention is warranted; disclosure of otherwise-confidential information is expressly permitted by Health Insurance Portability and Accountability Act regulations when an imminent hazard exists.” (D)

“Here are 10 of the most talked-about strategies that have been floated to stop mass shootings, and how likely they are to work.

Assault weapons ban. High-capacity magazine ban. Funding CDC research into gun violence. Universal background checks. Gun violence restraining orders or red flag laws. Arming teachers. Active shooter drills. Having students, faculty, and staff report potential threats. Banning violent video games. ‘Hardening schools’” (E)

“In our work at the School of Public Health we are making gun owners part of the solution. My colleague Cathy Barber is working with gun owners, gun advocates, gun trainers, and gun shop owners. Together they are finding common ground and developing solutions. The first area where they have found much common ground is around suicide. The evidence is overwhelming that a gun in the home increases the risk of suicide. More people die from gun suicide than gun homicide, and the people dying are gun owners and their families. Cathy has helped get gun shops in 20 states to play a role in reducing suicide. One grass-roots education effort includes guidelines on how to avoid selling or renting a firearm to a suicidal customer. To activate gunners, you need the right message and the right messenger. And the right messenger isn’t Harvard or public health professionals, it is responsible gun owners themselves. She is hoping to expand her focus to work on preventing guns from moving from the licit to the illicit market. Gun advocates have great ideas; they know about guns; and they are big into safety, so there are large potential benefits to get them to work together with public health professionals. That’s the goal.” (F)

“Following two mass shootings last weekend that ended the lives of 31 people, seven leading medical organizations have said “enough” and called for action to prevent gun-related injuries and deaths.

In the aftermath of the back-to-back mass shootings in Ohio and Texas that shook the country, the leaders of the physician and public health organizations called for immediate action to prevent gun violence in a special article published Wednesday in the Annals of Internal Medicine, the publication of the American College of Physicians (ACP).

“We are living in a world where gun violence is becoming increasingly common, and as physicians, we have a responsibility to address this public health crisis and to keep our patients safe and healthy,” said ACP President Robert McLean, M.D., in a statement.

In addition to the ACP, the article was authored by the physicians who lead the American Academy of Family Physicians, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Psychiatric Association, and the American Public Health Association…

“We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731,000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths,” the doctors wrote. The leaders of the physician organizations were joined by the American Public Health Association.

In the article, they suggest numerous steps to ending gun violence including addressing high-capacity magazines and firearms. “The magnitude and frequency of mass attacks are unacceptable to our organizations. A common-sense approach to reducing casualties in mass shooting situations must effectively address high-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity,” the physician leaders wrote.” (G)

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