The past few weeks have seen gun violence and the role of physicians become a national topic of conversation. In the wake of the Pittsburgh synagogue mass shooting, the National Rifle Association said doctors expressing opinions about firearms should “stay in their lane,” prompting enormous backlash from emergency physicians and others. Then, just yesterday, healthcare workers at Chicago’s Mercy Hospital (including a physician) themselves became victims of gun violence.
We thought it would be timely to once again share with our readers an interview from last May with MedPage Today blogger F. Perry Wilson, MD, and Garen Wintemute, MD, professor of emergency medicine and director of the Violence Prevention Research Program at the University of California Davis, and one of the world’s leading experts on gun violence.
Dr. Perry Wilson: Sandy Hook, Stoneman Douglas, Mandalay Bay, Sutherland Springs, Pulse Nightclub — the parade of mass shootings continues in front of our eyes every day to the point where I fear that this list will be incomplete by the time you may be watching this video. But from a public health standpoint, these mass shootings barely register. In 2017, 590 Americans were killed during mass shootings, but 35,000 Americans were killed by guns, with roughly two-thirds being suicides. To discuss the impact of guns and gun violence on health in the United States, I’m joined today by Dr. Garen Wintemute. Dr. Wintemute is a professor of emergency medicine and director of the Violence Prevention Research Program at UC Davis and one of the world’s leading experts on gun violence.
Dr. Wintemute, thank you for joining me on Doc-to-Doc.
Garen Wintemute, MD: Thanks for having me.
Wilson: Let me start off with a question that is perhaps surprisingly controversial. We are two doctors talking about gun violence. Why are we here? Is gun violence a public health issue?
Wintemute: We’re here because the problem is here. I think the best response to your question I’ve ever heard came from David Satcher just after he took over as head of CDC in the mid-1990s. And he said — this is an exact quote — “If it isn’t a health problem, then why are all these people dying from it?” As you point out, the daily toll is on the order of a hundred people a day. I can make a comparison: In the last 10 years, we have lost more civilians to firearm violence in the United States than we had combat fatalities in World War II. It’s a real problem.
What’s different is the advent and the increasing awareness of public mass shootings. Again, as you pointed out in your introduction, they account for no more than 1%-2% of all the deaths from firearm violence, but they’re the one subset of firearm violence about which no one can write a story that puts themselves and their loved ones not at risk. So public mass shootings are in the process of changing the character of American public life. We all have a stake in it.
Wilson: Mass shootings, you’re right, come home in some dramatic ways. I’m here [video-]shooting in Connecticut. Sandy Hook was traumatic for the whole state. I have young children. You’re exactly right. There’s no way to sort of tell yourself, “Oh, well. I’m safe. That doesn’t happen in my part of town,” or “That kind of thing doesn’t happen to people I know.” How has the rate of these mass shootings and the rate of gun violence on the whole change over time? I mean, my perception, just watching the news, is that it’s getting worse, and worse, and worse. Is that incorrect? What does the data show?
Wintemute: It depends on what you mean by firearm. So I need to purge this out. Overall, there had been no change whatsoever in the rate of firearm violence — and I combine homicide and suicide when I talk about violence — from the beginning of the 21st century until just a couple of years ago. Homicide was actually slowly declining. Suicide was increasing, and they offset each other, such that the overall trendline was as flat as a table.
In the last 2 years, for which we have data — the most recent year is 2016 — suicides continue to climb, but now homicide is also going up. So on balance, we have an increase.
Wilson: You mentioned that gun violence is essentially stable over time in the United States, and yet, the United States, compared to other countries, has a dramatically elevated rate of gun violence. Why do you think this is? What’s special about the U.S.?
Wintemute: You are right. This is absolutely a case of American exceptionalism that I think we would all just as soon be done away with. There are lots of pieces to the answer, but the piece that we need to talk about is the prevalence of firearm ownership in the United States.
We have something like 4%-5% of the world’s population. We control something like 45% of all firearms in civilian hands. There are more firearms in civilian hands in the United States than there are adults — almost more than there are people. This is sometimes put up to let firearms off the hook. We are not inherently a violent society. If you look at data on assault in the United States and compare us to other countries we would like to be compared to, OECD countries, Organization for Economic Cooperation and Development, advanced industrialized nations in Europe, and Australia, and Japan, and so on, our rates of assault in violence are actually toward the bottom. What’s different is that we have easy access, easier access, to a technology that changes the outcome.
Wilson: Give me a sense of the … There’s a magnitude of difference here, so gun ownership in the U.S. versus some comparable western country, and I don’t see Canada as another country with a sort of rich frontier history or rugged individualism history being compared to the U.S. in terms of gun ownership. Can you give us a sense of how we compare to some of those countries?
Wintemute: Sure. I think we could put Australia into the mix. The same sort of sense of frontier spirit settled by immigrants as we all are, a mythology of founding-ness that involved the use of firearms. But Canada and Australia approach firearms in a dramatically different way than the United States does. They regulate them. Handgun ownership is not easily accomplished in either of those countries. Long guns can more readily be purchased, but there still needs to be a reason for the purchase.
And one of the examples of effective population-based intervention actually comes from Australia where … and it’s particularly relevant, since we’re talking about mass shootings. Australia went through a particularly mass shooting at Port Arthur in Tasmania. If I recall correctly, 32 people were killed, and Australia is a much smaller country than we are, population-wise. Australia took an extraordinary step: They undertook what we all call a buyback. But it’s not like buybacks of firearms in the Unites States, where participation is voluntary. This was mandatory. They recovered essentially an entire class of firearms: semiautomatic weapons of the sort that turn out, not surprisingly, to be used disproportionately in mass shootings. Something over a million firearms were recovered. They compensated the owners, so it’s called the buyback. The intent of that intervention 20-some years ago was to prevent mass shootings, and Australia has not had a single mass shooting since then.
We won’t ever do something like that here, but whether it’s Canada, or Australia — or Israel, or Switzerland, which are two other countries that are sometimes thrown up as models where firearm ownership is common and so on — in those countries, firearm ownership is common. It’s also very highly regulated.
Wilson: So it strikes me that there are some policy measures that we could undertake to address the issue of mass shootings. There are some policy measures that we could undertake to address the issues of gun violence in general, which is … to be fair, although maybe less flashy, a much bigger issue. Some of those policy measures overlap, some of them don’t. An example, banning bump stocks doesn’t seem, to me, like something that is going to make a dent in gun violence overall. Although, perhaps it would make some change in some certain subtypes of mass shootings. Can you lay out some of the policy items that we could conceivably implement in the U.S. to make a different in gun violence?
Wintemute: For mass shootings, a policy option is on the table that we’re actually studying here in California. It’s been around for a couple of years. That’s what we call the gun violence restraining order. I’m going to spend a moment just on terms. That term was carefully and deliberately chosen. The media sometimes talk about these as “red flag laws,” and we are working very hard to have that term not be used, for two reasons: One, it stigmatizes people and the focus of this policy is on behavior, as I’ll describe in just a second.
But the other that it’s an alarmist sort of term. It’s fear-mongering, and there’s enough fear on the streets about these events already. A gun violence restraining order does this: when an individual is demonstrably at high risk of imminent harm, whether it’s to others or themselves, as it’s implemented here in California, members of the family or members of law enforcement can go to a judge as they would for domestic violence — our statue was patterned after our domestic violence statute — and basically say, “Your Honor, we’ve got a big problem here. We think something really terrible is about to happen, and firearms are part of the equation,” and the judge, following specific rules of evidence if she or he agrees, can issue an order that prohibits the individual from purchasing or possessing firearms.
That order is served typically by law enforcement in California, because risk is high and guns are involved. It comes with a search warrant, if needed, and the guns are recovered. Or because we have a 10-day waiting period here in California, sometimes the situation, and I know of cases as I say this, sometimes the situation is that mass violence is threatened, but the person doesn’t own a gun yet. They bought one, but were in our 10-day waiting period, and during the 10-day waiting period, the order is petitioned or issued, the purchase is blocked, and the shooting does not occur.
I know for a fact about a workplace mass shootings that was threatened that did not occur. I know for a fact about a terrorist shooting involving an AR, AR Rifle, but not yet taken into possession by the customer. That transaction was blocked by a gun violence restraining order.
I bring this up because it’s quite clear in retrospect that had a gun violence restraining order mechanism been available to be used in Florida, Parkland would not have happened. Nicholas Cruz was sending off all kinds of signals. There was no subtlety about it. Law enforcement was aware. Law enforcement dropped the ball. We can’t fix that part, but they could, had it been available, have requested a gun violence restraining order, and that firearm could have been recovered. Florida, since Parkland, has adopted a gun violence restraining order statute, and something like 20 other states are considering them.
Wilson: So I think it’s so important that you brought up some of these specific cases, because one of the things I hear all the time when we talk about this is that, “Look. You can implement whatever policy you want, but someone whose intent is to do harm and to do evil is going to find a way around it, right? They can get a gun if they want a gun. This is America after all.” Is that not true? In other words, how hard is it to obtain a gun illegally in the United States, compared to how hard is it to obtain a gun legally in the United States?
Wintemute: One of the myths in the United States is that violent criminals can’t buy guns legally. That’s just not true. Unless the crime they’ve been convicted of is a felony, or involves domestic violence under federal law, they can have a record of violent crime convictions as long as their arm, and still buy all the guns they want. California changed its law, and we looked at two groups of people who tried to buy handguns. Everybody in both groups had a violent misdemeanor conviction or more than one, and they were very similar demographically and so forth. The only meaningful difference was that one group sought to buy its guns under the last couple of years of the old policy, and they got them. And the other group tried to buy its guns under the first year of the new policy, and those purchases were denied.
The denied group had a reduction in risk of arrest for a firearm-related or violent crime of 25%-30%, which as your audience knows, is a big effect in the first 3 years following their attempt to purchase, as compared to the people who got their guns. And it was an observational study. It wasn’t a randomized trial, but one of the things we noticed, one of the things we looked for and found, I should say, is that this effect, this reduction in risk, was limited to the types of crimes the law was intended to prevent. There was no difference whatsoever in subsequent risk of arrest for crimes that did not involve firearms or violence. And as your audience knows, that sort of specificity of the fact is one of the criteria that allow us to increase our confidence in a causal relationship from an observational study.
Wilson: We’ve spoken a lot about policy, about government, about the fake statistics. I want to just finish thinking about the individual physician. I’m a physician, I care about gun violence. I care about the health of my patients. I can call my congressman, I can vote, but what can I do in my office with that patient that’s in front of me to address this issue, if anything?
Wintemute: It think this is hugely important for a couple of reasons. One is lots and lots and lots of physicians and other health professionals want to do something. And number two, we’re in a unique position because we see patients. We see patients at times in particular trouble in their lives, and we have an opportunity to intervene or start a chain of events that will lead to intervention. And the point I make, and I’ve written about this, and we’ve actually just yesterday, or 2 days ago now, launched a website to help make this happen.
The recommendation has been, just ask. You don’t have to ask everybody, but when there are risk factors for violence in the future that are clean in the interview, when those little antennae are up that we all have that say, “Something is not right here, and guns might be part of the problem.” Ask the patient, ask their family if they have access to firearms, and if so, initiate a conversation about whether that access right at this time is a good idea. There are articles and in our new website, there is information and links to the articles that provide very specific instruction, or I’ll say, guidelines … We’re not being prescriptive. Guidelines on exactly how to ask question, exactly what to do with the answers, which may vary from state to state.
But that’s something that doctors can do that, to be honest, nobody else can do. And we’re not doing it because we are anti-gun or pro-gun control. I don’t use that term, and I have to say, I enjoy shooting. I’ve given it up along with other things just for a lack of time. I’m not an anti-gun person. I am an anti-violence person, but it’s a way in which we can, uniquely we, can initiate a chain of events that might prevent violence. I’m an ER doc. If I’m seeing somebody because they’re suicidal, this is easy. I know I have to ask those questions. It’s the person who’s here for an injury for an assault who’s drunk, who brags about violent behavior. It’s the woman whose partner is violent. I’m going to think, “Hmm. I wonder if guns are part of the situation, and if maybe something should be done to reduce their role, their potential role, for creating harm in the future.”
Wilson: Dr. Wintemute, thank you very much for joining me today. This has been a really fascinating discussion.
Wintemute: It’s been a real pleasure. Thanks very much for having me.