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Physician Groups Issue Joint Call to Action on Firearms Injury Prevention
Physician Groups Issue Joint Call to Action on Firearms Injury Prevention by ERIC BERGER Special Contributor to Annals News & Perspective
P
resident Obama was furious. In April 2013, barely a few months after the Sandy Hook Elementary School shootings in which 20-year-old Adam Lanza killed 20 children and 6 adult staff members, the president had just watched his centerpiece gun control measure flame out in the US Senate. Flanked by former congresswoman Gabrielle Giffords in the Rose Garden, speaking with clipped words, Obama said, “It came down to politics, the worry that that vocal minority of gun owners would come after them in future elections. All in all, this was a pretty shameful day for Washington.” This initial rejection from Congress does not mean groups who deal with firearm-related injuries are giving up. In February, the American College of Emergency Physicians (ACEP) joined 7 other health professional organizations and the American Bar Association in a “call to action” for a series of measures aimed at reducing the health consequences of firearms. Volume 65, no. 5 : May 2015
“Quite simply, we view this as a public health problem in this country,” said Dean Wilkerson, MBA, JD, ACEP’s executive director. ACEP partnered with the American Academy of Family Physicians, American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, American College of Surgeons, and American Psychiatric Association, along with the American Public Health Association and the American Bar Association, in signing the call to action. The recommendations include universal background checks on gun purchasers, elimination of physician “gag” laws, restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearmrelated injuries and deaths. The organizations also called for improved access to mental health services. After the Newtown shooting, ACEP revisited its firearm policy and, in doing so, largely affirmed earlier versions, which decried the level of intentional and accidental US firearm injuries and sought some measures to
try to curb them. Then, in the summer of 2014, Wilkerson said he began discussing gun policies with Steven Weinberger, chief executive of the American College of Physicians. The policies held by each organization were similar, Wilkerson said, and there was a desire to advance the national discussion on the issue. “Steven said he’d really like to see [the] nation’s leading health organizations that are affected by this issue come together to move the needle, to increase the conversation,” Wilkerson recalled. All of the organizations had a general sense that although the Second Amendment was an important part of the Constitution, there could be reasonable limits on amendments. Wilkerson cited Oliver Wendell Holmes Jr.’s famous opinion from a 1919 US Supreme Court case concerning the First Amendment, in which Holmes wrote, “The most stringent protection of free speech would not protect a man falsely shouting fire in a theater and causing a panic.” To ensure that their recommendations were consistent with the Second Amendment, the health organizations coordinated with the American Bar Association, which confirmed that none of the measures conflicted. The call to action casts firearm-related injuries as a major public health issue because more than 32,000 people die each year in the United States because of firearm-related violence, suicides, and accidents. They are the second leading cause of death because of injury after motor vehicle crashes for adults and adolescents. That is a striking statistic to Wilkerson, who, before joining ACEP in Annals of Emergency Medicine 13A
2004, spent more than a decade as executive director of Mothers Against Drunk Driving. It took time and prolonged effort at both the state and federal level, Wilkerson recalled, to crack down on drunk driving and reduce deaths and injuries in motor vehicle crashes. Better research led to an increase in the drinking age to 21 years and a requirement that Americans wear seat belts. All along the way, advocates of these measures battled restaurants, the alcohol industry, and civil liberties groups. “We didn’t want to ban cars or alcohol, of course,” Wilkerson said. “But when we look at guns, there are commonsense things that can be done to reduce injuries due to firearms. It’s not going to happen overnight, but we could see reasonable progress over the next 5 to 10 years.” Beyond issuing their call to action, the public health groups do not have formal plans to lobby Congress and the White House together. However, Wilkerson said, in their individual lobbying efforts they will be able to point to the joint statement to show a unified front among physicians who treat the results of firearm incidents.
TO DO LIST
A
mong the legislative priorities that ACEP has adopted for 2015 in Congress are the following issues that relate to firearms: Expand availability of mental health services and research to improve treatment and decrease mentally unstable individuals’ access to firearms. Work with members of Congress to promote efforts that may prevent firearm-related injuries or deaths. Support private and public initiatives to fund firearm research. Although there has been virtually no action on firearms at the federal
14A Annals of Emergency Medicine
level since the Sandy Hook shootings, there has been some movement at the state level in both directions. According to the Law Center to Prevent Gun Violence, an organization that promotes gun laws, state legislatures have passed about as many laws to strengthen gun regulations as those that have weakened them. Robert Bazuro, DO, an emergency physician at Danbury Hospital whose children attended Sandy Hook Elementary but survived the shootings, has been involved in grassroots efforts for sensible gun reform during the last 2 years while serving on the committee that reviewed ACEP’s firearm policy in 2013. He agreed with Wilkerson that policy change would come only through persistent efforts. “To me, the take-home message of firearm injuries is that this is a public health issue, and it needs some balance,” Dr. Bazuro said. “I own firearms, and I do shoot. But I also believe there have to be some commonsense changes. I think at the end of the day, everyone wants to keep people safe. People want to have firearms to protect their family, but they don’t want to go out and harm other people. Eventually, I think there will be some meaningful change, but this will be a marathon.” One of the reasons it may take a long time is that the leading advocate for firearms, the National Rifle Association (NRA), does not appear willing to compromise. The organization, with an intense, multimillion-dollar lobbying effort, won in Washington, DC, and many state capitals after Sandy Hook as gun control groups sought an array of measures in 2013 and 2014. What may seem commonsense changes to physicians’ organizations are antithetical to the NRA. A few days after the physician groups’ call to action was published in February, an article appeared on the NRA’s Institute for Legislative
Affairs Web site in response, titled “Grandstanding Doctors and Lawyers Call for Gun Control.” With the call to action, argued the NRA article, the physicians and lawyers “strained their credibility and made fools of themselves.. These doctors and lawyers might want to educate themselves. Better yet, they should stick to medicine and law, rather than dabble in matters in which they have little understanding and zero practical experience. For bunion removal or estate planning, doctors and lawyers have a lot to offer. When serving as the gullible mouthpieces for a political agenda, they do themselves and the good standing of their professions a disservice.”
A SUCCESSFUL STRATEGY
S
ociologists familiar with the NRA, such as Monica Brasted, MA, PhD, at the College at Brockport in New York, said the organization thrives on polarization of the issue. It is a successful strategy—after Sandy Hook, the organization’s membership surpassed 5 million for the first time. From a policy standpoint, the organization has also been strikingly effective. For example, in 2011, Florida passed the Privacy of Firearm Owners law, which prohibits physicians from “making written inquiry or asking questions concerning the ownership of a firearm or ammunition by the patient or by a family member of the patient.” This gag order was upheld in the wake of the Sandy Hook shootings by a federal appeals court in 2014. The NRA also has successfully opposed federal funding for firearms. In January 2013, just a month after the shootings in Newtown, President Obama launched a number of executive efforts to address firearm injuries and deaths, among them a presidential memorandum that freed the Volume 65, no. 5 : May 2015
Centers for Disease Control and Prevention, as well as the National Institutes of Health, to fund firearm research grants. “The Secretary shall begin by identifying the most pressing research questions with the greatest potential public health impact, and by assessing existing public health interventions being implemented across the Nation to prevent gun violence,” the president ordered. To that end, 5 months later, the Institute of Medicine and National Research Council issued a report highlighting 5 “high-priority” areas: the characteristics of gun violence, risk and protective factors, prevention and other interventions, gun safety technology, and the influence of video games and other media. “Although this research agenda is an initial, not all-encompassing set of questions, it could help better define the causes and prevention of firearm violence in order to develop effective policies to reduce its occurrence and impact in the [United States],” said Alan Leshner, MS, PhD, chair of the study committee and former chief executive officer of the American Association for the Advancement of Science. “Similar approaches to public health problems have produced successes in lowering tobacco use, accidental poisoning, and motor vehicle fatalities.” But as of late 2014, just 1 National Institutes of Health grant had been funded, $168,000 to public health researchers in Colorado to study not gun violence, but rather “restrictions for discharge of suicidal patients in
Volume 65, no. 5 : May 2015
emergency care.” The reason for this is that Congress has not appropriated any funds for firearm research, despite the President’s request and the National Academies report saying such information was sorely needed by the country.
LIFTING THE BAN
I
n some sense it is helpful that the ban on federal funding for firearm research has ended, said Megan Ranney, MD, MPH, an assistant professor in the Department of Emergency Medicine at Rhode Island Hospital/Alpert Medical School of Brown University. Researchers no longer have to worry about being blackballed for further funds if firearms come up during a particular course of study, she said. However, funding from private foundations is insufficient to find the kind of broad-based research needed to better understand firearm injuries and deaths and to identify efficacious ways to reduce them. And until such money flows from federal sources, Ranney does not expect researchers to move directly into firearms research. “We all try to do good science,” she said. “But we also write grants for things that are more likely to get funded. The quest to get grant money right now is somewhat chaotic already, and no one wants to tilt at windmills.” Ranney is part of a subcommittee to ACEP’s research committee that is working to define the firearm research questions most relevant to emergency medicine. They are looking
at addressing questions such as who should be screened for being at a high risk of firearm injury, and whether the emergency department or primary care physician’s office is the best place to conduct an intervention. Without good research, she said, it is difficult to make sound policy decisions. That is why one of ACEP’s primary legislative goals is a call to fund such research, Wilkerson said. It is the necessary first step to any effective and permanent reform measures. “The NRA is trying to cast our group as being antigun or having an agenda along those lines,” Wilkerson said. “That is not the case. Many of us happen to be conservative. We can also recognize a public health problem when we see it.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed. 2015.03.015
Annals of Emergency Medicine 15A
P
resident Obama was furious. In April 2013, barely a few months after the Sandy Hook Elementary School shootings in which 20-year-old Adam Lanza killed 20 children and 6 adult staff members, the president had just watched his centerpiece gun control measure flame out in the US Senate. Flanked by former congresswoman Gabrielle Giffords in the Rose Garden, speaking with clipped words, Obama said, “It came down to politics, the worry that that vocal minority of gun owners would come after them in future elections. All in all, this was a pretty shameful day for Washington.” This initial rejection from Congress does not mean groups who deal with firearm-related injuries are giving up. In February, the American College of Emergency Physicians (ACEP) joined 7 other health professional organizations and the American Bar Association in a “call to action” for a series of measures aimed at reducing the health consequences of firearms. Volume 65, no. 5 : May 2015
“Quite simply, we view this as a public health problem in this country,” said Dean Wilkerson, MBA, JD, ACEP’s executive director. ACEP partnered with the American Academy of Family Physicians, American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, American College of Surgeons, and American Psychiatric Association, along with the American Public Health Association and the American Bar Association, in signing the call to action. The recommendations include universal background checks on gun purchasers, elimination of physician “gag” laws, restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearmrelated injuries and deaths. The organizations also called for improved access to mental health services. After the Newtown shooting, ACEP revisited its firearm policy and, in doing so, largely affirmed earlier versions, which decried the level of intentional and accidental US firearm injuries and sought some measures to
try to curb them. Then, in the summer of 2014, Wilkerson said he began discussing gun policies with Steven Weinberger, chief executive of the American College of Physicians. The policies held by each organization were similar, Wilkerson said, and there was a desire to advance the national discussion on the issue. “Steven said he’d really like to see [the] nation’s leading health organizations that are affected by this issue come together to move the needle, to increase the conversation,” Wilkerson recalled. All of the organizations had a general sense that although the Second Amendment was an important part of the Constitution, there could be reasonable limits on amendments. Wilkerson cited Oliver Wendell Holmes Jr.’s famous opinion from a 1919 US Supreme Court case concerning the First Amendment, in which Holmes wrote, “The most stringent protection of free speech would not protect a man falsely shouting fire in a theater and causing a panic.” To ensure that their recommendations were consistent with the Second Amendment, the health organizations coordinated with the American Bar Association, which confirmed that none of the measures conflicted. The call to action casts firearm-related injuries as a major public health issue because more than 32,000 people die each year in the United States because of firearm-related violence, suicides, and accidents. They are the second leading cause of death because of injury after motor vehicle crashes for adults and adolescents. That is a striking statistic to Wilkerson, who, before joining ACEP in Annals of Emergency Medicine 13A
2004, spent more than a decade as executive director of Mothers Against Drunk Driving. It took time and prolonged effort at both the state and federal level, Wilkerson recalled, to crack down on drunk driving and reduce deaths and injuries in motor vehicle crashes. Better research led to an increase in the drinking age to 21 years and a requirement that Americans wear seat belts. All along the way, advocates of these measures battled restaurants, the alcohol industry, and civil liberties groups. “We didn’t want to ban cars or alcohol, of course,” Wilkerson said. “But when we look at guns, there are commonsense things that can be done to reduce injuries due to firearms. It’s not going to happen overnight, but we could see reasonable progress over the next 5 to 10 years.” Beyond issuing their call to action, the public health groups do not have formal plans to lobby Congress and the White House together. However, Wilkerson said, in their individual lobbying efforts they will be able to point to the joint statement to show a unified front among physicians who treat the results of firearm incidents.
TO DO LIST
A
mong the legislative priorities that ACEP has adopted for 2015 in Congress are the following issues that relate to firearms: Expand availability of mental health services and research to improve treatment and decrease mentally unstable individuals’ access to firearms. Work with members of Congress to promote efforts that may prevent firearm-related injuries or deaths. Support private and public initiatives to fund firearm research. Although there has been virtually no action on firearms at the federal
14A Annals of Emergency Medicine
level since the Sandy Hook shootings, there has been some movement at the state level in both directions. According to the Law Center to Prevent Gun Violence, an organization that promotes gun laws, state legislatures have passed about as many laws to strengthen gun regulations as those that have weakened them. Robert Bazuro, DO, an emergency physician at Danbury Hospital whose children attended Sandy Hook Elementary but survived the shootings, has been involved in grassroots efforts for sensible gun reform during the last 2 years while serving on the committee that reviewed ACEP’s firearm policy in 2013. He agreed with Wilkerson that policy change would come only through persistent efforts. “To me, the take-home message of firearm injuries is that this is a public health issue, and it needs some balance,” Dr. Bazuro said. “I own firearms, and I do shoot. But I also believe there have to be some commonsense changes. I think at the end of the day, everyone wants to keep people safe. People want to have firearms to protect their family, but they don’t want to go out and harm other people. Eventually, I think there will be some meaningful change, but this will be a marathon.” One of the reasons it may take a long time is that the leading advocate for firearms, the National Rifle Association (NRA), does not appear willing to compromise. The organization, with an intense, multimillion-dollar lobbying effort, won in Washington, DC, and many state capitals after Sandy Hook as gun control groups sought an array of measures in 2013 and 2014. What may seem commonsense changes to physicians’ organizations are antithetical to the NRA. A few days after the physician groups’ call to action was published in February, an article appeared on the NRA’s Institute for Legislative
Affairs Web site in response, titled “Grandstanding Doctors and Lawyers Call for Gun Control.” With the call to action, argued the NRA article, the physicians and lawyers “strained their credibility and made fools of themselves.. These doctors and lawyers might want to educate themselves. Better yet, they should stick to medicine and law, rather than dabble in matters in which they have little understanding and zero practical experience. For bunion removal or estate planning, doctors and lawyers have a lot to offer. When serving as the gullible mouthpieces for a political agenda, they do themselves and the good standing of their professions a disservice.”
A SUCCESSFUL STRATEGY
S
ociologists familiar with the NRA, such as Monica Brasted, MA, PhD, at the College at Brockport in New York, said the organization thrives on polarization of the issue. It is a successful strategy—after Sandy Hook, the organization’s membership surpassed 5 million for the first time. From a policy standpoint, the organization has also been strikingly effective. For example, in 2011, Florida passed the Privacy of Firearm Owners law, which prohibits physicians from “making written inquiry or asking questions concerning the ownership of a firearm or ammunition by the patient or by a family member of the patient.” This gag order was upheld in the wake of the Sandy Hook shootings by a federal appeals court in 2014. The NRA also has successfully opposed federal funding for firearms. In January 2013, just a month after the shootings in Newtown, President Obama launched a number of executive efforts to address firearm injuries and deaths, among them a presidential memorandum that freed the Volume 65, no. 5 : May 2015
Centers for Disease Control and Prevention, as well as the National Institutes of Health, to fund firearm research grants. “The Secretary shall begin by identifying the most pressing research questions with the greatest potential public health impact, and by assessing existing public health interventions being implemented across the Nation to prevent gun violence,” the president ordered. To that end, 5 months later, the Institute of Medicine and National Research Council issued a report highlighting 5 “high-priority” areas: the characteristics of gun violence, risk and protective factors, prevention and other interventions, gun safety technology, and the influence of video games and other media. “Although this research agenda is an initial, not all-encompassing set of questions, it could help better define the causes and prevention of firearm violence in order to develop effective policies to reduce its occurrence and impact in the [United States],” said Alan Leshner, MS, PhD, chair of the study committee and former chief executive officer of the American Association for the Advancement of Science. “Similar approaches to public health problems have produced successes in lowering tobacco use, accidental poisoning, and motor vehicle fatalities.” But as of late 2014, just 1 National Institutes of Health grant had been funded, $168,000 to public health researchers in Colorado to study not gun violence, but rather “restrictions for discharge of suicidal patients in
Volume 65, no. 5 : May 2015
emergency care.” The reason for this is that Congress has not appropriated any funds for firearm research, despite the President’s request and the National Academies report saying such information was sorely needed by the country.
LIFTING THE BAN
I
n some sense it is helpful that the ban on federal funding for firearm research has ended, said Megan Ranney, MD, MPH, an assistant professor in the Department of Emergency Medicine at Rhode Island Hospital/Alpert Medical School of Brown University. Researchers no longer have to worry about being blackballed for further funds if firearms come up during a particular course of study, she said. However, funding from private foundations is insufficient to find the kind of broad-based research needed to better understand firearm injuries and deaths and to identify efficacious ways to reduce them. And until such money flows from federal sources, Ranney does not expect researchers to move directly into firearms research. “We all try to do good science,” she said. “But we also write grants for things that are more likely to get funded. The quest to get grant money right now is somewhat chaotic already, and no one wants to tilt at windmills.” Ranney is part of a subcommittee to ACEP’s research committee that is working to define the firearm research questions most relevant to emergency medicine. They are looking
at addressing questions such as who should be screened for being at a high risk of firearm injury, and whether the emergency department or primary care physician’s office is the best place to conduct an intervention. Without good research, she said, it is difficult to make sound policy decisions. That is why one of ACEP’s primary legislative goals is a call to fund such research, Wilkerson said. It is the necessary first step to any effective and permanent reform measures. “The NRA is trying to cast our group as being antigun or having an agenda along those lines,” Wilkerson said. “That is not the case. Many of us happen to be conservative. We can also recognize a public health problem when we see it.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed. 2015.03.015
Annals of Emergency Medicine 15A