Gun violence is a public health issue

At our last visit, she asked me “not to forget us” and gave me a photograph of her family. She included a picture of her daughter, whom I had never met. I had missed her by four years almost to the day because she was shot and killed driving through her neighborhood in the middle of the afternoon.

I first met Mrs. P early in my training as a physician in New Orleans, a city with a rate of gun violence on par with cities in South America. She had many uncontrolled chronic diseases, requiring over ten daily medications, and at least quarterly medical visits; she frequently missed both doses and appointments. As an eager intern, I had tried to clean up her med list, ask about transportation, and prescribe only from the $4 lists at local pharmacies in hopes of decreasing barriers to care. After a few months, it became clear that her limitation was care itself — and the fact that she didn’t. Since the loss of her daughter, she had stopped caring what happened to herself.

Many of my patients are survivors of Hurricane Katrina, so I have a low threshold to screen for depression and its triggers. Mrs. P was indeed severely depressed, so much so that her voice was almost unchanged as she told me how her daughter had been caught in a shower of gunfire while running errands a few years prior.

After three years working with Mrs. P, she is finally beginning to heal.  I have treated her with enough success that she feels well enough to control many of her previously persistent physical medical problems.

But she thanked me “for caring” only when I disclosed my personal efforts to speak out and advocate for gun sense policies. She requested only more frequent visits to discuss her suffering “with someone who cared,” and at our final visit — my last clinic visit of all of residency — the woman whose grief had prevented her from speaking more than one-word statements, brought me pictures of her entire family, “so that (I wouldn’t) forget them.”

Two weeks after that appointment, I have not forgotten the importance of speaking up for my patients and my community, but it seems like the medical world still doesn’t know. A man opened fire in Orlando’s Pulse nightclub, killing 50 and injuring as many more. Whatever personal healing I had facilitated with that one patient seemed to be universally negated by the devastation of an entire community. As a physician, it felt like a rigged game of whack-a-mole, in which each mind eased required triple that number to suffer.

And yet part of the argument made against physicians’ involvement in the search for gun sense legislation is that it is not our problem. In his address the morning after the attack, President Obama said, “To actively do nothing is a decision, as well.” To date, the medical community has yet to unite against gun violence. This week, the American Medical Association — the largest professional organization of physicians in the United States — is meeting, and participants somehow still disagree about the role we play in this conversation.  (Update: The AMA House of Delegates declared gun violence a public health crisis and called for an end on research ban.)

As a physician, I see the physical and emotional repercussions of gun violence without having to watch the news. And yet it is difficult to screen for exposure, particularly in communities where it is prevalent and comorbid with other sources of depression and trauma. In New Orleans, there has been an average of more than one shooting each day — in a city less of than 400,000 people. At the state level, Louisiana has the second-highest rate of firearm-related deaths in the country, and is one of only four states in which the majority of those deaths are homicides, not suicides. In the United States, 88 people on average die every day from gun violence.

Some may say it is not “my job” to address gun violence. And yet, as a primary care physician, I am trained to look for patterns at individual and at population levels, to assess for risks, and to intervene early in order to prevent illness and death. I may not have pills to prevent gun violence, or tests to predict my patients’ or their loved ones’ deaths. But I do have a voice, and I have a community of colleagues whose collective voice has led the efforts to change policies and prevent deaths from other public health threats like obesity and tobacco.

There is no longer any doubt that gun violence is a public health issue, costing lives and livelihood. Nationally, firearm-related violence (homicide, suicide, and unintentional shooting) is the third-leading cause of death in young people, accounting for 10.6 deaths per 100,000 people (after poisoning and motor-vehicle accidents). Evidence suggests that gun violence accounts for almost $50 billion in medical (direct) and work loss (indirect) costs annually. The issue is discussed regularly now not only in public health publications, but aggressively in flagship journals of the medical field.

Death from gun violence is higher than death from hypertension and renal failure in the United States, and yet we, as primary care physicians, have no guidelines for screening or preventing that threat, nor global, concerted campaigns to take action toward risk reduction. Admittedly, there is a dearth of strong data supporting any particular public health or legal interventions to prevent gun violence — primarily because of a federal ban on funding for this type of research.

Observational studies suggest that the single most effective policy for keeping guns out of the hands of dangerous people and saving lives is requiring a criminal background check for all gun sales. President Obama’s recent executive order began this process; however, there is still work to be done. Background checks are not fully universal, nor do they ban purchases by those committing certain offenses — including those with restraining orders from non-married partners, despite the fact that more women in the U.S. are killed by their dating partners than by their spouses. The executive actions are progress, but in cities like mine, more is needed — from both the government and from the medical community.

I cannot begin to imagine the suffering of Orlando this week. But I can say that those who survive — the men and women from Pulse as well as the families and friends of those who perished, like my patient, Mrs. P — are all victims. Their injuries are widespread, deep, and long-lasting. I am certain that I am not the only physician who cares that her patients are victims of preventable deaths.

But the only way that our patients know we care is if we say so — with our words and with our actions. Now is the time for the medical community to follow the president’s executive order with professional action: updated recommendations, guidelines, and advocacy. Like any gunshot wound that continues to bleed, even the most complex agents cannot compete with holding pressure.

Sarah Candler is an internal medicine physician.

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