In 1965, Ralph Nader published Unsafe at Any Speed: The Designed-In Dangers of the American Automobile to draw public attention to the high rate of death and disability resulting from motor vehicle crashes in the U.S.1 Mr. Nader subsequently testified before Congress, which led to the National Traffic and Motor Vehicle Safety Act of 1966.2 That landmark legislation mandated that automobiles be equipped with basic safety features, such as seat belts, padded dashboards, and shatter-resistant windshields. This act also established the Department of Transportation, which evolved into the National Highway Traffic Safety Administration (NHTSA) in 1970. The NHTSA established data systems to track motor vehicle fatalities across the U.S. and supported research to develop interventions to address this public health crisis.
Although the parallels are imperfect, if we mirror the public health approach taken to address motor vehicle safety, it is likely we can significantly reduce injuries and deaths related to firearms.
Fifty years later, through a multifaceted public health approach, which included addressing roadway and vehicle safety features and efforts to modify driver behavior, we have witnessed a dramatic decline in mortality. Achieving this goal required recognition of the problem and a commitment to address it at both the federal and state levels. It required regulation of the vehicle manufacturers, upgrades to roadway infrastructure, state legislation to require use of safety devices and impose consequences for intoxicated driving, and public awareness campaigns to change driver behaviors. It required investment in research to understand the most effective interventions and the support of the entire health care community to advise patients how best to keep their families safe. Notably, now more people in the U.S. die per year from firearm injuries than motor vehicle collisions.
A public health approach to firearm injury and death
What can we learn from the public health approach to roadway and vehicle safety today as we face the challenge of nearly 40,000 deaths per year in the U.S. from firearm injury? This public health epidemic is especially sobering when you also consider the untold number of nonfatal injuries and an increasing incidence of mass shooting events. How can we raise awareness at both the state and federal levels? How can we make firearm ownership safer? What injury prevention interventions will make a difference?
Although the parallels are imperfect, if we mirror the public health approach taken to address motor vehicle safety, it is likely that we can significantly reduce injuries and deaths related to firearms. A challenge in dealing with the issue of firearm injury is that we often get caught in a polarizing political debate regarding the right to firearm ownership. As co-author of this article Ronald M. Stewart, MD, FACS, Medical Director, American College of Surgeons (ACS) Trauma Programs, points out in an article published in the Journal of the American College of Surgeons, “Freedom with responsibility: A consensus strategy for preventing injury, death and disability from firearm violence,” the chasm is not as wide as it seems, and though people may hold firmly to their views regarding the benefits or harms of firearm ownership, a large majority agree that we must act to reduce unnecessary death and disability.3 The ACS Committee on Trauma (COT) has developed a common narrative focused on identifying and addressing the underlying causes of violence while making firearm ownership as safe as possible. This approach recognizes firearm ownership as a constitutionally protected liberty, while moving forward together to reduce unnecessary deaths and suffering among our patients, our colleagues, and our communities.
In a comprehensive approach to this issue, in February 2018 the ACS Board of Regents approved a nine-point strategic action plan to address firearm violence, including support for the following initiatives:
- Engage in trauma system development and promulgation of the Stop the Bleed® program
- Create a Firearm Strategy Team (FAST) Workgroup of firearm-owning surgeons to inform injury prevention and advocacy
- Survey all U.S. ACS members on their views regarding firearm injury prevention
- Develop collaborative partnerships with other organizations
- Implement firearm injury prevention initiatives by the ACS COT Injury Prevention Committee
- Develop a research agenda and advocate for federal and private research funding
- Promote responsible firearm ownership and nonviolent conflict resolution
- Advocate for increased mental health funding
- Support expanded background checks
A major component of this nine-point strategic action plan was to engage firearm owners as part of the solution by forming the FAST Workgroup. This team includes surgeons who own firearms for hunting, sport shooting, self-defense, law enforcement, and military service. Analogous to engaging bicyclists to help develop an action plan to decrease bicycle injuries, the ACS engaged members who own firearms to help develop durable and informed injury prevention and advocacy strategies. Although their recommendations do not represent the perspective of all firearm-owning ACS members, this group’s initial suggestions addressed ownership, registration, licensure, education and training, mandatory reporting and risk mitigation, safety innovation and technology, research, culture of violence, social isolation, and behavioral health.2
Because addressing this problem requires a multidisciplinary approach, the College hosted a historic Summit on Firearm Injury Prevention in February, which brought together 43 major medical and injury prevention organizations and the American Bar Association to build consensus and collaboration on a public health approach to minimize death and disability related to firearm injuries in the U.S. The three objectives of the summit were as follows: identify opportunities for the medical community to reach a consensus-based, nonpartisan approach to firearm injury prevention; discuss the key components of a public health approach and define interventions this group will support; and develop consensus on actionable items for firearm injury prevention using the public health framework.
The publication of the proceedings from this conference demonstrated the commitment of the professional medical and legal community to address this public health crisis. The proceedings provide a road map for a comprehensive public health approach that can be implemented through collaboration among medical, legal, and community organizations (see Figure 1). The report summarizes the activities of each participating organization and includes nine consensus statements that were subsequently supported by 47 medical and injury prevention organizations (see Table 1).
Figure 1. Visual abstract from February 10–11, 2019, Medical Summit on Firearm Injury Prevention
Source: Bulger EB, Kuhls DA, Campbell BT, et al. Proceedings from the Medical Summit on Firearm Injury Prevention: A Public Health Approach to Reduce Death and Disability in the U.S. J Am Coll Surg. May 2019. Available at: https://doi.org/10.1016/j.jamcollsurg.2019.05.018.5
Table 1. Organizations that support the consensus statements from the Medical Summit on Firearm Injury Prevention
Briefly summarized, these consensus statements include the following recommendations:4
- Recognize firearm injury as a U.S. public health crisis and take a comprehensive public health and medical approach to address it
- Research this public health crisis using a disease model and call for research funding at federal and philanthropic levels commensurate with the burden of the disease on society
- Engage firearm owners and communities at risk as stakeholders to develop firearm injury prevention programs
- Empower the medical community across all health care settings to counsel patients and families on safe firearm storage, screen for patients at risk of firearm injury, and engage the community in addressing the social determinants of injury and violence through partnerships with hospitals and health care systems
- Commit professional stakeholder organizations to ensure that these statements lead to constructive actions for improving the health and well-being of our nation
The road ahead
A comprehensive public health approach requires an in-depth understanding of the epidemiology of violence and culturally competent, evidence-based interventions. This tactic will require significant investment in firearm injury prevention research. In March, Dr. Stewart testified before the U.S. Congress on the ACS’ support for dedicated Centers for Disease Control and Prevention and National Institutes of Health funding for firearm injury prevention research.
The medical summit proceedings also outline the evidence for specific interventions to address suicide, unintentional injury, and intentional interpersonal violence, such as counseling patients and families regarding safe storage of firearms, lethal means safety for suicide prevention, hospital-based violence intervention programs, identifying patients at risk for violence, the relationship between mental health and firearm injury, and issues of public policy. The medical community can implement many of these practical interventions without the need for political debate or policy change.
A comprehensive public health approach requires an in-depth understanding of the epidemiology of violence and culturally competent, evidence-based interventions.
The ACS COT Injury Prevention Committee is working with partners from the summit to develop resources to support the implementation of these strategies. In addition, the report highlights the need to address the social determinants of health that contribute to structural violence in our communities. Under the leadership of Rochelle Dicker, MD, FACS, the ACS is convening a collaborative working group of experts to develop strategies in this regard. This team will be known as ISAVE—Improving Social Determinants to Attenuate Violence—and will complement the ongoing efforts of the FAST Workgroup. These two workgroups are aligned with the strategy of understanding and addressing the root causes of violence while making firearm ownership as safe as possible.
Although this journey has just begun and much work needs to be done, the ACS COT is committed to solving this complex problem. As trauma surgeons, we witness the tragic consequences of firearm injury every day. We believe that by investing in research and empowering the professional community to address this issue, we can achieve the same success we have had in the reduction of death and disability from motor vehicle collisions. As Dr. Stewart and colleagues wrote, “The time is now for political differences to be set aside, for polarizing and incendiary language to be avoided, and for our energies to be devoted to thoughtful policy development and specific actions in the context of a public health model.”3 The Proceedings from the Medical Summit on Firearm Injury Prevention provides a road map for those seeking to implement practical, collaborative injury prevention programs in their communities.
- Nader R. Unsafe at Any Speed: The Designed-In Dangers of the American Automobile. New York, NY: Grossman Publishers; 1965.
- National Traffic and Motor Vehicle Safety Act of 1966, P.L. 89-63 (1966). Available at: www.govinfo.gov/content/pkg/STATUTE-80/pdf/STATUTE-80-Pg718.pdf. Accessed August 6, 2019.
- Stewart RM, Kuhls DA, Rotondo MF, Bulger EM. Freedom with responsibility: A consensus strategy for preventing injury, death, and disability from firearm violence. J Am Coll Surg. 2018;227(2):281-283.
- Talley CL, Campbell BT, Jenkins DH, et al. Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I. J Am Coll Surg. 2019;228(2):198-206.
- Bulger EM, Kuhls DA, Campbell BT, et al. Proceedings from the Medical Summit on Firearm Injury Prevention: A public health approach to reduce death and disability in the U.S. J Am Coll Surg. May 18, 2019. Available at: https://doi.org/10.1016/j.jamcollsurg.2019.05.018. Accessed August 16, 2019.