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Abstract
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In 1995, Annals published the American College of Physicians' (ACP) first position paper identifying firearm injury as a public health issue and justified that position with data documenting that firearms accounted for 38 000 U.S. deaths and were the leading cause of death in Black men ages 15 to 34 years (1). ACP asserted that the prevention of firearm injury by public health methods is as much a responsibility for physicians as is the treatment of its victims, recommended that physicians counsel patients about firearm safety, and advocated for research to inform strategies to reduce firearm injuries. In the 29 years since, deaths in the United States due to suicide and homicide by firearm have steadily increased. In 2022, more than 48 000 persons in the United States died by firearms, and guns were a leading cause of death for children, teens, and young Black men (2). ACP updated the organization's position in 2014 (3) and again in 2018 (4).
Although staggering, firearm deaths reflect only 1 facet of firearms' adverse health effects. Also affecting health are nonfatal injury with resulting disability and caregiver burden as well as the adverse mental health impact of living in places where firearm injury is commonplace. In their article, Kaufman and colleagues expand our knowledge about the extent of both fatal and nonfatal firearm injuries (5). In 2019 to 2020, using data from the Centers for Disease Control and Prevention and the Nationwide Emergency Department Sample, they identified 252 376 total firearm injuries that resulted in 84 908 deaths. They report that rates of self-harm by firearm were highest among White persons (11 per 100 000), followed by Native Americans, and were also increasing among Black youth. The rates of firearm assault were highest among Black persons (70.1 per 100 000) as were accidental injuries (56.1 per 100 000). Kaufman and colleagues state that for every firearm death, more than twice as many persons injured by firearms survive. The survivors experience a lifetime of physical, mental, and social costs, including medical care and loss of productivity.
While rates of firearm injury climb, what has happened in the policy realm?
In 1994, Congress authorized a 10-year assault weapon ban. The ban expired in 2004 despite several attempts to reauthorize it. Estimates are that there are currently more than 20 million AR-style rifles in the United States, including ones used in horrific school shootings and the July 2024 attempt to assassinate a former U.S. president.
In 1996, the Dickey Amendment essentially prohibited federal funding for firearm injury prevention research. It took until 2022 for Congress to reappropriate funds to the National Institutes of Health and Centers for Disease Control and Prevention for firearm injury research. The United States lost 24 years of opportunity to understand firearm injury and how to prevent it.
In 2008, the Supreme Court ruled in District of Columbia v. Heller that the Second Amendment guarantees a person the right to possess firearms independent of service in a state militia and to use firearms for traditionally lawful purposes, including self-defense within the home. This ruling essentially strengthens interpretation of the Second Amendment.
After the 2017 mass shooting at a Las Vegas music festival that killed 57 persons and injured 411, the Bureau of Alcohol, Tobacco, Firearms and Explosives prohibited the production, sale, and possession of bump stocks. In June 2024, the Supreme Court rejected this ruling because a bump stock works by a "single function" of the trigger but does not do so "automatically," as stipulated in the law restricting machine guns. A bump stock can cause a semiautomatic weapon to fire at rates of 400 to 800 rounds per minute, perpetuating a mechanism for rapid injury to many.
A sharp increase in gun ownership began before and escalated during the COVID-19 pandemic (6). Between January 2019 and April 2021, an estimated 5.7 million U.S. adults became new gun owners. Most lived in homes that previously were without guns. Not surprising, firearm homicides and mass shootings also increased during the pandemic. The U.S. firearm homicide rate in 2020 was the highest recorded since 1994, and 2021 was the worst year for mass shootings (defined as killing or injuring 4 or more persons, not including the shooter) since they began to be tracked in 2013 (7, 8). In 2022, the Supreme Court ruled in New York State Rifle and Pistol Association v. Bruen that any restrictions on gun ownership had to conform to the "history and tradition" of firearm regulations stretching back to the 18th century. This ruling essentially allows handguns to be carried in most public settings, so the United States now has more guns than ever being carried in more places than ever.
Whereas the above developments counter efforts to reduce firearm injury, some policy actions aim to reduce firearm injury. The 2022 Bipartisan Safer Communities Act increased funding for mental health services, expanded background checks for purchasers younger than 21 years, provided funding for extreme risk protection orders, and narrowed the "boyfriend loophole" to prohibit firearm purchases by any romantic partner found guilty of a domestic violence charge. The Bipartisan Safer Communities Act also allocated $250 million over 5 years for community violence intervention programs.
Twenty-one states have passed legislation creating extreme risk protection orders designed to empower families, law enforcement, and health care professionals to petition a judge to temporarily deny access to firearms to persons deemed to be at high risk for harming themselves or others.
Another positive development was the Supreme Court's June 2024 opinion in United States v. Rahimi that upheld a federal law preventing anyone placed under a domestic violence restraining order from possessing a gun.
ACP and Annals continue to view firearm injury as a public health issue that requires a multipronged public health approach that engages physicians and other clinicians counseling patients, community-based interventions, research, and policy action that focus on making it harder rather than easier for persons at risk for harming themselves or others to get their hands on a gun. Several medical professional coalitions have joined ACP to amplify our voices (8). Annals has published tools to help physicians more comfortably speak with their patients about reducing the risk for firearm injury (9). Reducing firearm injury and death is very much in physicians' lane. Kaufman and colleagues' findings make it obvious that we need to stay in this lane.
Language: en |