Gun Violence: A Public Health Concern?

June 9, 2016

gunsBy Matthew B. McNeill, MD

Peer Reviewed

One can often feel numb or indifferent to the seemingly nightly reports of gun deaths on American news programs. Individual homicides, suicides, or accidental gun deaths are tragic and tragically commonplace. However, over the last two decades, a tide of unrest with the current role of guns in America has arisen in the wake of mass school shootings in places such as Jonesboro, AR (1998, 5 killed, 10 injured), Columbine, CO (1999, 13 killed, 24 injured), Red Lake Indian Reservation, MN (2005, 9 killed, 7 injured), Nickel Mines, PA (2006, 5 killed, 5 injured), Blacksburg, VA (2007, 32 killed, 17 injured), Newtown, CT (2012, 27 killed, 1 injured), and Roseburg, OR (2015, 9 dead, 9 injured); as well as large public shootings in Aurora, CO, Washington D.C., Ft. Hood, TX, Charleston, SC, and San Bernardino, CA. Initially reserved to the political class and social activists, the call for action on firearms has reached a fever pitch as it has become more visible to the general public. While the debate and consideration of the right to possess firearms and ammunition is best left to legal authorities and Constitutional scholars, the over 30,000 annual deaths by firearm must at least prompt the consideration of gun violence as a significant public health concern.

The Current Legal Precedent

Before assessing the current state of gun violence in the United States, it is important to understand the legal precedent for gun ownership. The Second Amendment to the United States Constitution states “a well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Over the course of American history, there have been numerous interpretations and re-interpretations of these twenty-seven words. The current legal precedent was established by two recent Supreme Court cases. The first, District of Columbia v. Heller (2008), was a 5-4 ruling that the 2nd amendment protects the individual’s right to keep and bear arms unconnected with any militia, most specifically for purposes of hunting or self-defense.[[i]] The ruling allowed for limited restriction including banning firearm possession by felons and mentally ill, limiting access in sensitive places such as schools and government building, and limiting sales of firearms so they could be closely monitored. The ruling also struck down the Firearms Control Regulations Act of 1975 which had previously required trigger locks and restricted ownership of handguns. While this initial decision only applied to Washington, DC, a subsequent court case, McDonald v. Chicago (2010), extended this ruling to all cities and states.[[ii]]

The Second Amendment and Physicians

In the setting of the McDonald decision and the debate over the Affordable Care Act in 2010, there began push-back over the role of physician in discussing gun ownership with patients. In 2011, Florida was the first state to pass a restriction on physician-patient encounters concerning firearms. The Firearm Owner’s Privacy Act (2011) restricted licensed health care practitioners and facilities from entering information concerning a patient’s ownership of firearms into the patient’s medical record that the practitioner knows is “not relevant to the patient’s medical care or safety, or the safety of others.”[[iii]] It maintained the practitioners “shall respect a patient’s right to privacy and should refrain” from inquiring as to whether a patient or his or her family owns firearms, unless the practitioner or facility believes in good faith that the “information is relevant to the patient’s medical care or safety, or the safety of others.” Further it averred that practitioners “may not discriminate” against a patient on the basis of firearm ownership” and “should refrain from unnecessarily harassing a patient about firearm ownership.” A physicians’ organization, angered at what they perceived as a restriction of their right to free speech, sued the state in an attempt to strike the law down. The so-called “Docs v. Glocks” or Wollschlaeger v. Governor of Florida (2011) case initially found the law to be unconstitutional, however on appeal and re-appeal to the 11th Circuit Court of Appeal, the law was upheld as constitutional as it only limits speech in a permissible profession-client setting and mostly serves as restriction on physician conduct.[[iv]] This decision is currently being appealed the Supreme Court of the United States. Since 2011, 14 other states have passed similar “firearm gag” laws on physicians.[[v]]

Gun Violence As A Public Health Issue

Both the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) consider violence to be a public health threat.[[vi],,[vii]] The American College of Physicians has referred to gun violence as an “epidemic” since 1995.[[viii]] To put things in perspective, in the United States, the Spanish flu of 1918-1919 caused 500,000 deaths.[[ix]] Annually, influenza causes around 23,607 deaths in the United States.[[x]] In the U.S. in 2013, there were 33,169 deaths by firearm (more than 80 per day); of which 11,208 were homicide,  21,175 were suicide with a firearm, 505 were due to accidental discharge of a firearm, and 281 were due to firearms-use with “undetermined intent.”[[xi]] A 2011 Department of Justice analysis described 478,400 fatal and non-fatal violence crimes with firearms annually in the U.S. [[xii]] The annual rate of homicide by firearm per 1 million people in England and Wales is 0.7, Germany 1.7, and Canada 5.1, while the United State’s rate is 29.7 deaths; an annual rate 6 to 30 times higher than its peer nations. [[xiii]]

Like all public health concerns (HIV/AIDS, cancer, diabetes, etc.), data collection and research is vital to evidence-based policy development. Although the funding for the National Institutes of Health and the CDC is $30.1 billion and $11.1 billion annually respectively, since 1996 there has been a ban on funding firearm related research. [[xiv],,[xv]] A 1996 funding bill, influenced by the National Rifle Association, included a rider that “none of the funds made available for injury prevention and control may be used to advocate or promote gun control”.[[xvi]] This has stymied the quality and quantity of gun violence research for the last two decades. In 2013, President Obama clarified in an executive order that agencies are instructed to “conduct or sponsor research into the causes of gun violence and the ways to prevent it” but still no funding or law change has occurred in Congress.[[xvii]] In January 2016, President Obama again released an executive order with specific deadlines and funding guidelines regarding research and implementation of gun safety technology.[[xviii]] The ultimate outcome of this new order or any change in policy and/or funding is still to be determined. 

What Is Known With The Research We Have

While new research may take years and careful political navigation to come to fruition, there presently exists some data on the issue of firearm safety. A 1992 study published in the New England Journal of Medicine on suicide and gun ownership found that guns in the home are associated with an increased risk of completed suicide (adjusted OR 4.8).[[xix]] A similar study from 1993 published in the NEJM found guns in the home are associated with an increased risk of homicide (adjusted OR 2.7).[[xx]] In terms of safe firearm storage, a 2000 study found that among homes with children and firearms, 43% had at least 1 unlocked firearm (i.e., not in a locked place and not locked with a trigger lock or other locking mechanism).[[xxi]] Appropriate firearm storage is a valid concern as demonstrated in a 2005 publication in JAMA on gun storage practice and the risk of youth suicide and unintentional firearm injuries. Comparing gun owning households with adolescents, guns in households with adolescent firearm events (suicide, unintentional, violent) were less likely to be stored unloaded (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.16-0.56), less likely to be stored locked (OR, 0.27; 95% CI, 0.17-0.45), stored separately from ammunition (OR, 0.45; 95% CI, 0.34-0.93), or to have ammunition that was locked (OR, 0.39; 95% CI, 0.23-0.66) than were control guns in households without events.[[xxii]] In terms of suicide, which is the 10th leading cause of death in the US, studies have shown that 45% of victims have contact with their primary care physician within one month of their suicide.[[xxiii]] Around 50% of suicides are by firearm, and suicides make up the largest portion of firearm deaths.[[xxiv]]

What Can A Health Provider Do

Both the American Medical Association and the American College of Physician have released strong policy statements regarding the physician role in preventing gun violence. Along with a plea for increased gun violence research, a prohibition on assault rifles and high-capacity ammunition, increased funding for mental health services, and more stringent background checks, there are some suggestions for how individual providers can make a difference.[[xxv],,[xxvi]] Much like obese patients or tobacco users are at increased risk for diabetes and hypertension, it is important to identify and screen patients who are at high risk for firearm injury.

Providers should screen for potential self or homicidal gun violence in patients:

  • With a recent psychiatric hospitalization
  • Following a prolonged medical hospitalization
  • Living in households with adolescents
  • With severe depression

Additionally, given the often strong dedication to the absolute right to gun ownership, it is more prudent to focus on gun storage as opposed to gun removal.

Providers should encourage all gun owner to:

  • Keep guns locked
  • Keep guns unloaded
  • Store ammunition locked
  • Store ammunition in separate location from the firearm

The most important impact that physicians can have in addressing firearm safety is by lobbying for and conducting more research on effective methods of preventing firearm-related morbidity and mortality. In a culture where scientific outcome and evidence-based decision-making has great influence in policy and societal ideals, hopefully the medical community can be a force in addressing this controversial yet very real public health epidemic.

Dr. Matthew B. McNeill, MD is a 3rd year resident at NYU Langone Medical Center

Peer reviewed by David Alfandre, MD., Medical Ethics, NYU Langone Medical Center

Image courtesy of Wikimedia Commons


[[i]] Supreme Court of the United States. District of Columbia et al. v. Heller. Published June 26, 2008. Accessed January 19, 2016.

[[ii]] Supreme Court of the United States. McDonald et al. v. City of Chicago, Illinois. Published June 28, 2010. Accessed January 19, 2016.

[[iii]] Florida House of Representatives. Firearm Owner’s Privacy Act. Published June 2, 2011. Accessed January 19, 2016.

[[iv]] Volokh, Eugene. Court upholds Florida law restricting doctor-patient speech about guns. The Washington Post. Published July 29, 2015.

[[v]] Khazan, Olga. The Strange Laws That Dictate What Your Doctor Tells You. The Atlantic. Published October 16, 2015.

[[vi]] World Health Organization. Violence and Injury Prevention. Published 2016. Accessed January 19, 2016.

[[vii]] Centers for Disease Control and Prevention. The Public Health Approach to Violence Prevention. Published March 25, 2015. Accessed January 19, 2016.

[[viii]] Butkus R, Doherty R, Daniel H. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Annals of internal medicine. 2014 Jun 17;160(12):858-60.

[[ix]] U.S. Department of Health & Human Services. The Great Pandemic: The United States in 1918–1919. Revised 2016. Accessed January 19, 2016.

[[x]] Centers for Disease Control and Prevention. Estimates of Deaths Associated with Seasonal Influenza-  United States, 1976—2007. Published August 27, 2010. Accessed January, 19, 2016.

[[xi]] Centers for Disease Control and Prevention. Deaths: Final Data for 2013. Updated February 16, 2015. Accessed January 19, 2016.

[[xii]] US Department of Justice. Firearm Violence, 1993-2011. Published May 2013. Accessed January 19, 2016.

[[xiii]] Rogers, Simon. Gun homicides and gun ownership listed by country. The Guardian. Published July 22, 2012.

[[xiv]] National Institutes of Health. Budget. Updated October 14, 2015. Accessed January 19, 2016.

[[xv]] US Department of Health and Human Services. HHS FY 2015 Budget in Brief. Published June 4, 2014. Accessed January 19, 2016.

[[xvi]] Stein, Sam. The Congressman Who Restricted Gun Violence Research Has Regrets. The Huffington Post. Published October 6, 2015.

[[xvii]] The White House. Presidential Memorandum – Engaging in Public Health Research on the Causes and Prevention of Gun Violence. . Published January 16, 2013. Accessed January 19, 2016.

[[xviii]] The White House. FACT SHEET: New Executive Actions to Reduce Gun Violence and Make Our Communities Safer. Published January 4, 2016. Accessed January 19, 2016.

[[xix]] Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. New England Journal of Medicine. 1992 Aug 13;327(7):467-72.

[[xx]] Kellermann AL, Rivara FP, Rushforth NB,  et al. Gun ownership as a risk factor for homicide in the home. New England Journal of Medicine. 1993 Oct 7;329(15):1084-91.

[[xxi]] Schuster MA, Franke TM, Bastian AM, et al .Firearm storage patterns in US homes with children. American Journal of Public Health. 2000 Apr;90(4):588.

[[xxii]] Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. Jama. 2005 Feb 9;293(6):707-14.

[[xxiii]] Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry. 2014 Nov 9.

[[xxiv]] American Association of Suicidology. U.S.A. SUICIDE: 2014 OFFICIAL FINAL DATA. Published December 22, 2015. Accessed January 19, 2016.

[[xxv]] American College of Physicians. American College of Physicians offers policy recommendations for reducing gun-related injuries and deaths in the U.S. Revised 2016. Accessed January 19, 2016

[[xxvi]] American Medical Association. Violence Prevention. Revised 2016. Accessed January 19, 206.

One comment on “Gun Violence: A Public Health Concern?

  • Avatar of Joe O'Donnell
    Joe O'Donnell on

    “In a culture where scientific outcome and evidence-based decision-making has great influence in policy and societal ideals…”
    Ummm, well, we WISH this were true….

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