Firearm Injuries as a Public Health Issue

In 2011, firearm injuries accounted for 32 163 deaths in the United States, nearly as many as the 34 677 fatalities from motor vehicle traffic accidents. The total includes 19 766 suicides, 11 101 homicides, and 851 deaths from the accidental discharge of firearms.¹ Homicide is 1 of the top 5 causes of death in persons aged 1 to 44 years, and suicide is 1 of the top 5 causes of death in persons aged 10 to 44 years.² Yet federal law prohibits all Department of Health and Human Services (DHHS) agencies, including the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health, from using funds, “in whole or in part, to advocate or promote gun control.”³ The ban has applied to the CDC since 1996, and, more recently, to the entire DHHS.⁴ The meaning of the clause is not clear—preventing firearm injuries and gun control are related but are not synonymous—but it has effectively ended federal support of gun research. Kellerman and Rivara⁴ note that at the CDC, “no federal employee was willing to risk his or her career or the agency's funding to find out [what the clause meant]. Extramural support for firearm injury prevention research quickly dried up.”

The federal government's neglect of firearm injuries as a public health issue is a national shame that should be urgently corrected. Reducing lives lost to gun violence is a public health issue about a major mechanism of fatal injury, not a Second Amendment to the US Constitution issue about “the right of the people to keep and bear arms.” Following the mass shooting of school children and educators at Sandy Hook Elementary School in Newtown, Connecticut, in December 2012, the CDC's website offered little information to people trying to understand and prevent such violent events. The CDC's “A-Z Index” has no listing for either “guns” or “firearms,” and the 24 topics on the “Injury, Violence & Safety” web page include explosion and blast injuries and fireworks, but not firearms. Indeed, federal health officials rarely speak about any aspect of firearms injury, violence, and safety.

The mass killing in Connecticut shows once again the high price our society pays for ignoring legal reforms and other measures, including improvements in the mental health system, which would help to reduce gun violence and save lives. The needed reforms, as outlined by Kassirer⁵ in a Viewpoint article in this journal, include banning assault weapons and large-capacity ammunition-feeding devices; extending registration, background checks, and waiting periods from some to all gun purchases; and manufacturing safer guns. The Bureau of Alcohol, Tobacco, Firearms, and Explosives, the agency that enforces federal firearm regulations needs leadership; the agency has not had a permanent full-time director since 2006. The bureau also should be freed from legislative restrictions that obstruct its ability to do its work, such as the limit on unannounced inspections of a gun dealer to 1 a year and the prohibition on establishing a central computer database of gun sales records.⁶ These and many other long-overdue reforms do not require further study, only the political will to implement them.

In 2011, Florida enacted a law that impeded physicians' ability to talk to their patients about the risks of guns, whether they own guns, and if so, how the guns are stored at home. Unfortunately, after a federal district court judge blocked enforcement, the state appealed, and the case is still pending. Physicians routinely ask patients potentially sensitive questions so they can help them to protect their health, and legislation should not inappropriately interfere with the physician-patient relationship.⁷

In the aftermath of the carnage at Sandy Hook, the Obama administration and Congress should act quickly to make the prevention of firearm injuries a pubic health priority. First, all federal health agencies, including the National Center for Injury Prevention and Control at the CDC, should regain the ability to fund research aimed at reducing injuries and deaths from firearms, regardless of whether some might label such research as “gun control.” Funding should be substantial for specific projects, as well as for research infrastructure and the training of investigators. President Obama should make a concerted effort to get the restrictive language about using federal funds “in whole or in part, to advocate or promote gun control” out of future appropriations bills. In 2004, a committee of the National Research Council^8(p3) highlighted the many unanswered questions about the relation between firearms and violence, noting that

if policy makers are to have a solid empirical and research base for decisions about firearms and violence, the federal government needs to support a systematic program of data collection and research that specifically addresses that issue.

Such a research program is needed now more than ever. Future laws and regulations should be informed by answers to more of the unresolved questions about what works to prevent firearm injuries.

Second, in 2002, the CDC initiated the National Violent Death Reporting System, a state-based surveillance system that pools information from various sources to provide a clearer picture of why violent deaths, including those related to firearms, occur and how they might be prevented. But a decade later, the annual funding of $3.5 million is only sufficient to support the operation of the system in 18 states. The Obama administration should request that Congress increase the funding so that the National Violent Death Reporting System can actually be a national system and provide nationally representative data.

Finally, President Obama should empower federal health officials to speak and provide leadership about firearm injuries and violence, the potentially intimidating legislative language in current law notwithstanding. The secretary of Health and Human Services, the Surgeon General, the director of the CDC, and the director of the CDC's National Center for Injury Prevention and Control should be allowed to protect the public health by working to reduce injuries and deaths from firearms, in the same way that they work to reduce injuries and deaths from poisonings, motor vehicle traffic accidents, and falls.

The Obama Administration's plan to reduce gun violence, announced on January 16, 2013, is an encouraging start to making the prevention of firearm injuries a public health priority.⁹ Although some of the provisions are already being implemented through executive actions, others require that Congress authorize funding or enact legislation. President Obama has directed the CDC and other federal scientific agencies to “conduct research into the causes and prevention of gun violence,” and his administration will “issue guidance clarifying that the Affordable Care Act does not prohibit or otherwise regulate communication between doctors and patients, including about firearms.”⁹ The administration has called on Congress to provide $10 million for the CDC to conduct gun violence research, and to provide an additional $20 million to expand the National Violent Death Reporting System from 18 states to all 50 states.⁹ Such funding is urgently needed, but in the long term considerably more money will be required.

Research and policy efforts to prevent injuries can make a big difference. The federal government has invested billions of dollars to better understand motor vehicle fatalities, and hundreds of thousands of lives have been saved.¹⁰ However, as traffic fatalities have steadily declined, gun-related deaths are trending upward, from a recent low point in 2000. If the United States were to get serious about preventing firearms-related injuries and deaths, thousands of lives could be saved each year. We can wait no longer to protect the public health.

Correspondence: Dr Steinbrook, Department of Internal Medicine, Yale School of Medicine, PO Box 208025, New Haven, CT 06520-8025 (rsteinbrook@attglobal.net).

Published Online: January 21, 2013. doi:10.1001/jamainternmed.2013.22