Shifting Our Approach to Gun Violence: A Public Health Crisis

Dr. Russell:
Every year gun violence injures or even kills tens of thousands of Americans. Shifting our approach to looking at gun violence as a disease from a public health standpoint may help clinicians manage the biological, behavioral, and social aspects of this disease. But what does this shift look like?

Welcome to Clinician’s Roundtable on ReachMD. I’m your host, Dr. John Russell. And here with us to share insights on gun violence disease is Dr. Stan Miller, the Executive Director at the Jefferson Center for Injury Research & Prevention. He’s also an Associate Professor of Surgery, Emergency Medicine, and Population Health at Jefferson Medical College.

Dr. Miller, welcome to the program.

Dr. Miller:
Thanks, John. It’s great to be here with you.

Dr. Russell:
So, Dr. Miller, let’s start with some framework on the disease of gun violence. How do these gun violence statistics correlate with public health?

Dr. Miller:
Well, John, you know, first of all, it’s very important in the field of injury science, which is what I do in my capacity as Director of the Jefferson Center of Injury Research and Prevention, to stress that scientific principles can be applied to injuries and therefore, principles of disease management, control, and prevention can be applied to any type of injury. The important thing here is given that our audience are mainly physicians is to view gun violence as a disease. And the American College of Surgeons actually formally classifies injury in general, and that includes gun violence as a surgical disease so that the same kind of principles of disease management, control, and most ideally prevention that you would apply to, let’s say, the disease of hypertension or diabetes, you can apply the same principles to the disease of gun violence.

Dr. Russell:
So, what are the barriers to reframing our approach to managing gun violence from a public health perspective?

Dr. Miller:
Well, public health in its most ideal form and mission is about complete prevention of the event. So, if any of our fellow physician colleagues in the audience think that just because a surgeon happens to be today’s guest that I’m going to start talking about needle and thread and different techniques to repair injuries from gun violence, they’re going to be disappointed because ultimately, we’re about complete prevention of the event from ever even occurring. As far as I’m concerned, and the American College of Surgeons, with the issue of gun violence in America, if a victim has shown up in our trauma bay or on our operating room table, we’ve already failed in society and we failed in our mission. I mean, obviously, I’m being a bit facetious there. Our job as surgeons, of course, is to tend to injury as trauma surgeons. But ultimately, public health is about complete prevention, and therefore, when you apply public health methodologies to the disease of injury, that’s where the present day challenge is. But adhering to our principles of disease management, control, and prevention, ultimately I feel very confident that one day we will have a significant impact in this issue.

Dr. Russell:
So, Dr. Miller, now let’s apply this new approach to clinical practice. What are some of the steps we need to take in order to approach gun violence as a public health issue?

Dr. Miller:
Well, first of all, historically, it’s rather interesting. The worlds of clinical medicine and public health have actually been miles apart, and it is only really, in my opinion, in the last 20, 25 years or so that those worlds now are becoming much closer. And I would submit that in the recent COVID pandemic, it was the worlds of clinical medicine and public health working together that actually to a large extent have gotten us to this point where we are now essentially out of the pandemic and into an epidemic kind of phase in that regard. And it’s that kind of view that I would apply to your question is that in order to really solve this issue, we need to get clinicians and public health professionals and all other stakeholders working in an interdisciplinary manner to begin addressing this issue.

Dr. Russell:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. John Russell, and I’m speaking with Dr. Stan Miller about gun violence disease.
So I’m a primary care doctor, and certainly a lot of public health starts in primary care. What are some resources clinicians like myself and my brethren can use to educate themselves on this approach to gun violence?

Dr. Miller:
Well, first of all, there are a number of resources posted in our own governing bodies, such as the American College of Surgeons, the American Academy of Pediatrics, the American Medical Association, so all you need to do is go to their websites, and they actually have toolkits that can enumerate all the different kinds of entities but to give some initial ideas.

There are resources, for instance, there is a big movement now for hospitals to become involved in implementing what are called hospital-based violence intervention prevention initiatives. So, if, for instance, as a primary care physician you have someone in front of you in your office who has been a victim of any type of gun violence, you could, for instance, refer them to an entity called Healing Hurt People as an example, which started in Philadelphia but is now being implemented across the country where that person could be placed in contact with a social worker, a case management worker, legal support, a trauma intervention specialist, who could work with that individual not just for one or two months but for a period of over a year where they help to get their life back in order, whether they are experiencing financial stress, legal stress, psychological stress, that potentially could predispose them to being victimized once again by gun violence. That’s one example.

Here in Philadelphia at Jefferson, we’re in the process of implementing a mobile van screening program in conjunction with our urology men’s health department where, while we are doing prostate screening in a mobile van program, we’re also going to be offering gun locks to those who are participating in the screening program. As a primary care physician, one of the most powerful things that you could do is to ask a patient ‘Do you have a gun in the house?’ If so, ‘Would you like me to put you in contact with a resource where you could purchase a gun lock?’ and even better, not only a gun lock but also a gun locker, and educate them about the risk of having a gun in the house that is not properly locked and stored. Other types of risk factor screening people tend to forget that suicide by firearm is a major, major issue, and so to introduce into a routine primary care or any physician discussion in an exam room, about suicide risk factors feeling that out. Those are some quick initial thoughts to answer your question.

Dr. Russell:
So, Dr. Miller, as we come to a close today, what are some key points you’d like our audience to take away?

Dr. Miller:
I think the key point here is, first of all, it’s going to take an interdisciplinary effort. It’s going to take the worlds of clinical medicine, the worlds of public health and all the other stakeholders, the world of criminal justice. I’ve had discussions with criminal justice personnel around the city of Philadelphia and around the country about applying not only the public health method but, what they call the criminal justice method. But ultimately, the big picture is this. I view addressing the gun violence crisis in the same way that this country took on the tobacco crisis going back into the early 1960s, that back then in the early 1960s, a dedicated group of professionals and the surgeon general’s office led an effort to finally take on the issue of tobacco and it’s absolute risk factor for lung cancer. And then what happened is it did not happen overnight but over a period of a number of years, even decades, we’re at the point where you have to look really hard to see someone smoking a cigarette walking down the street in any American city now and all the other good aspects about tobacco control and prevention that it took decades to implement, and I view addressing the gun violence crisis as that.

Unfortunately, we’re not going to solve the problem in a year. We’re not going to solve it in five years. We’re probably not even going to solve it in ten. But, hopefully, 30, 40 years from now, this country and internationally people will say ‘Thank goodness that there was a group of dedicated professionals and stakeholders from across an entire society who in the year 2023 decided to really significantly take on the issue of the gun violence crisis, and here we are 30, 40 years later we’re finally where we should be,’ and so that would be my greatest takeaway at this point is you need to start somewhere. Every journey of a thousand miles starts with a first footstep.

Dr. Russell:
Well, these insights might help not only better care for our patients but also help us prevent gun violence all together. But as we come to a close, I want to thank my guest, Dr. Stan Miller, for joining me today to talk about gun violence from a public health perspective.

Dr. Miller, it was a pleasure speaking with you today.

Dr. Miller:
John, thanks very much. Thank you for inviting me to be part of this roundtable.

Dr. Russell:
For ReachMD, I’m Dr. John Russell. To access this and other episodes in our series, please visit ReachMD.com/CliniciansRoundtable where you can be Part of the Knowledge. Thanks for listening.