Gun Violence is a Public Health Crisis and as Hospitalists, It’s Time to Step Up

I did not think that becoming a pediatric hospitalist would require me to become an expert in firearm injury, but here I am. Every day more than 300 people are shot in the United States.^1,2 That fact alone has forced me and every other hospitalist in the country to learn how to care for individuals with firearm injuries. But learning how to care for these patients is not enough. Firearm injuries are preventable, and we must use our expertise to help create a safer world for our patients and our communities. Gun violence is a public health crisis and we, as hospitalists, are not only qualified to advocate for change, we are obligated.

According to data recently released by the Centers for Disease Control and Prevention (CDC), there were more than 45,222 firearm-related deaths in the United States in 2020. This equates to roughly 124 people being shot and killed every single day.^1,2 This is the largest number of people killed by firearms in a single year on record. These numbers represent a 14% increase from 2019, and a 43% increase from 2010.²  When accounting for the growth in the population, the 2020 death rate was 13.6 per 100,000 people, which is lower than the peak of 16.3 per 100,000 in 1974, but still the highest we have seen since the mid-1990s.^2,3 And, for the first time ever, firearm injury has surpassed motor vehicle accidents as the number one cause of death in children.⁴  

These statistics are horrifying in and of themselves, but they do not begin to reflect the extent of the effect of firearm violence on individuals, communities, or health care systems. That’s because even though firearm injuries have a higher fatality rate than other forms of trauma or assault, the majority of gunshot injury victims do survive.⁵ Because of this, hospitalists, and physicians of all kinds, across the United States, have become experts in caring for these survivors.

As we all know, patients who survive the powerful injuries produced by firearms often face a long, complex, and excruciatingly painful physical recovery. Many of the injuries can have lifelong implications. Nearly half of all children who are admitted to the hospital after being shot leave with a physical disability.⁶ Hospitalists care for these patients for weeks or months in the hospital following their initial presentation. Some, particularly those with more devastating wounds, return time and time again for complications related to their original trauma. While research is limited regarding readmission rates over the course of their lifetimes, a 2019 study found that one in seven patients discharged from the hospital following a firearm-related injury was readmitted within six months. More than half of these patients were readmitted within the first 30 days.⁷

The physical injuries resulting from firearm violence are not the only wounds that need to be healed. Exposure to firearm violence is associated with elevated rates of depression, anxiety, post-traumatic stress disorder, and substance abuse. The “lucky ones” who survive gun violence are also at higher risk of dying by suicide.^6,8 Because of the shortage of mental health access throughout our country, individuals in crisis end up in our emergency departments over and over again. These individuals also become our patients in the hospital, as they often have no other place to go.

Victims of firearm violence often require lifelong multidisciplinary care, including frequent doctors’ appointments, treatments, and therapies. Providing this comprehensive health care is challenging within our current health care system for even the most resourced individuals. For those with additional barriers to care it is a monumental task. When considering that we know firearm violence disproportionately impacts people of color, people living in poverty, and other already marginalized communities, it is clear that firearm violence exacerbates some of the country’s worst disparities.⁸

The weight of this public health crisis on our health care system is enormous. While it is difficult to account fully for all the health care costs associated with a firearm injury, one analysis showed that the average cost of hospitalization per patient was $32,700. This same analysis found that between 2010 and 2015 the U.S. health care system spent more than $910 million annually on firearm-related inpatient admissions alone.⁷

Every day, as hospitalists, we take care of individuals with medical problems that are difficult, or even impossible, to predict or prevent. Firearm injury is not one of those. Firearm injury is completely preventable. To predict and prevent these injuries, however, we must approach firearm injury as the public health crisis that it is. This requires hospitalists to step beyond our clinical roles and into the role of advocates.

The CDC recommends a public health approach to firearm violence prevention that includes four critical steps; define and monitor the problem, identify risk and protective factors, develop and test prevention strategies, and assure widespread adoption.⁹ The heart of this approach relies on thorough, accurate, and timely data collection and research aimed at evaluating the effectiveness of injury-prevention efforts.

In 1996 the federal government implemented a funding freeze on injury-prevention research that could “be used to advocate or promote gun control.” This effectively cut off financial support for any research in this field.¹⁰ This freeze was finally lifted in the fiscal year 2020 when Congress included $25 million for gun violence research in a year-end spending bill. While a step in the right direction, we are still decades behind where we should be. Obtaining data on all aspects of this problem, as well as monitoring interventions, is critical, and is a potential area for hospitalists to contribute to life-saving research.

The data we do have, however, can and should be used for policymaking. We know that more stringent firearm legislation is associated with fewer deaths.¹¹ According to a Pew Research Center survey, a majority of Americans (53%), believe gun laws should be stricter than they are.¹² Despite this, the United States had not passed federal legislation regarding firearms in nearly 30 years prior to June 25, 2022, when the Bipartisan Safer Communities Act was signed by President Biden. While this bill represents important progress, it is not the final solution. Much of this bill supports state interventions. Our state legislators need to hear from us to help ensure the implementation of meaningful policy as a result of this bipartisan federal action.

As hospitalists, we are equipped to help our legislators by interpreting existing studies linking policy to outcomes. We are also in the unique position of putting a face to the data. It can be tempting to assume that legislators know how policies affect real humans, but the vast majority of policymakers are not physicians. They do not see the suffering we see. They are not at the bedside day and night comforting patients and their families whose lives will never be the same. They do not hold the heartbreak we hold. This work that we do is a profound privilege, but in doing it day in and day out, it is easy to forget that so few people see what we see. There will always be a divide between our understanding of this problem and that of policymakers. It is up to us to help bridge that gap.

While the importance of advocacy at the federal and state level cannot be overstated, there are other important ways we can advocate at the bedside as well. Counseling on firearm safety, including safe storage practices and distribution of gun locks, has been shown to influence patient behavior. While most of the studies have taken place in the outpatient setting, those that have looked at the translation of these programs to the inpatient setting have shown promising results.¹³  

As hospitalists, we have an incredibly important role to play. We know the awful details of how this public health problem plays out in real people’s lives.  We understand the data and the potential for relevant, meaningful interventions. While the political climate surrounding this topic can make advocacy intimidating, it does not need to be difficult. We do not need to be policy experts. We do not need to be political. We are experts in our field, and we simply need to be brave enough to stand up and share that expertise. We have so much power in this conversation, and we need to use it.

Dr. Gambill is a pediatric hospitalist and assistant professor of pediatrics at the University of Texas at Austin Dell Medical School.

References

1. Resources: Key Statistics. Brady Campaign to Prevent Gun Violence website. https://www.bradyunited.org/key-statistics. Accessed August 1, 2022.
2. WISQARS Data Visualization. Centers for Disease Control and Prevention website. https://www.cdc.gov/injury/wisqars. Accessed August 1, 2022.
3. Gramlich J. What the data says about gun deaths in the U.S. Pew Research Center website. https://www.pewresearch.org/fact-tank/2022/02/03/what-the-data-says-about-gun-deaths-in-the-u-s/. Published May 16, 2022. Accessed August 1, 2022.
4. Cunningham RM, et al. The major causes of death in children and adolescents in the United States. N Engl J Med. 2018;379(25):2468-2475. doi: 10.1056/NEJMsr1804754.
5. Kaufman EJ, et al. Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009-2017. JAMA Intern Med. 2021;181(2):237-244. doi: 10.1001/jamainternmed.2020.6696.
6. Schaechter, J and Hirsh, MP. Caring for Pediatric Patients After Gun Violence. In: Lee LK, Fleegler EW, eds. Pediatric Firearm Injuries and Fatalities: The Clinician’s Guide to Policies and Approaches to Firearm Harm Prevention. Switzerland. Springer Nature; 2021: 143-155
7. Spitzer SA, et al. Readmission risk and costs of firearm injuries in the United States, 2010-2015. PLoS One. 2019;14(1):e0209896. doi: 10.1371/journal.pone.0209896.
8. Martin R, et al. Racial disparities in child exposure to firearm violence before and during COVID-19. Am J Prev Med. 2022;63(2):204-212. doi: 10.1016/j.amepre.2022.02.007.
9. The Public Health Approach to Violence Prevention. Centers for Disease Control and Prevention website. www.cdc.gov/violenceprevention/about/publichealthapproach.html?CDC_AA_refVal=www.cdc.gov/violenceprevention/publichealthissue/publichealthapproach.html. Published January 18, 2022. Accessed August 1, 2022.
10. Jamieson C. Gun violence research: History of the federal funding freeze. American Psychological Association website. https://www.apa.org/science/about/psa/2013/02/gun-violence. Published February 2013 (archive). Accessed August 1, 2022.
11. Fleegler EW, et al. Firearm legislation and firearm-related fatalities in the United States. JAMA Intern Med. 2013;173(9):732-40. doi: 10.1001/jamainternmed.2013.1286.
12. Schaeffer K. Key facts about Americans and guns. Pew Research Center website. https://www.pewresearch.org/fact-tank/2021/09/13/key-facts-about-americans-and-guns/. Published September 13, 2021. Accessed August 1, 2022.
13. Silver AH, et al. Randomized controlled trial for parents of hospitalized children: keeping kids safe from guns. Hosp Pediatr. 2021;11(7):691-702. doi: 10.1542/hpeds.2020-001214.

Read more from the Journal of Hospital Medicine: Enough is enough: Our responsibility to prevent gun violence