Thursday, August 11, 2016

Do firearm counseling or legal restrictions reduce injuries and deaths?

An online reader of an American Family Physician article on prevention of unintentional childhood injury wondered why the article did not mention counseling about firearm safety. It was a fair question, since in the U.S. more than 7,000 youth under the age of 20 are hospitalized each year for injuries from firearms, and three-quarters of such injuries in children younger than 10 are unintentional (in contrast, most firearm injuries in adolescents are from assaults). According to a subsequent AFP editorial, studies suggest that counseling about safe gun practices such as storing firearms unloaded in locked containers and separately from ammunition may increase the use of such practices.

A national poll conducted last year found that two-thirds of non-firearm owners, and a majority of firearm owners, agreed that health care provider discussions about firearms are at least sometimes appropriate. Outside of Florida, there are no state legal restrictions on physicians' ability to ask patients about firearms, even the Florida statute (which was struck down by a U.S. District Court for violating the First Amendment and remains suspended pending a decision by the 11th Circuit Court of Appeals) contains exceptions. The authors of a perspective paper in the Annals of Internal Medicine recommend that physicians consider asking patients about firearm access when they are at acute risk of violence to self or others; have one or more individual level risk factors (e.g., a history of violence, substance abuse, serious mental illness); or belong to a demographic group at increased risk for violence or unintentional injury (older white men, young African American men, and children).

Although recent high-profile mass shootings have drawn attention to gun violence as a public health problem in the U.S., these represent only 1 in 50 gun homicides in the U.S., most of which are not committed with assault weapons. A recent New York Times analysis of two crowd-sourced databases of 358 shootings with 4 or more casualties found that most occurred in poor neighborhoods, and most victims were African American men in their twenties:

They [the databases] chronicle how easily lives are shattered when a firearm is readily available - in a waistband, a glove compartment, a mailbox or garbage can that serves as a gang's gun locker. They document the mayhem spawned by the most banal of offenses: a push in a bar, a Facebook taunt, the wrong choice of music at a house party. They tally scores of unfortunates in the wrong place at the wrong time: an 11 month-old clinging to his mother's hip, shot as she prepared to load him into a car; a 77 year-old church deacon, killed by a stray bullet while watching television on his couch.

Gun violence has been called an "epidemic" based on the disproportionate numbers of firearm homicide deaths in the U.S. compared to other nations, but also because it spreads much like a sexually transmitted disease within networks of people, where the victim one time becomes the assailant the next. Unfortunately, it isn't clear if legal restrictions (e.g., background checks, waiting periods, concealed carry laws, bans on certain types of firearms) can reduce injuries and deaths. A 2005 review by the Task Force on Community Preventive Services found insufficient evidence to determine the effectiveness of any law in preventing violence, and it doesn't appear eager to take up the topic again. Even though the Centers for Disease Control and Prevention is no longer forbidden from researching gun violence, it hasn't received any Congressional funding for such studies. So U.S. policymakers are left with extrapolating from observational studies, many done in other countries. These studies suggest that implementing multiple firearm restrictions simultaneously (as Australia did in 1996) is associated with reductions in deaths; that laws requiring background checks reduce intimate partner homicides; and that laws requiring safer storage of firearms reduce unintentional deaths in children.

Of course, meaningful firearm legislation in the U.S. remains politically impossible, especially when a Presidential nominee openly calls for "Second Amendment people" to assassinate his opponent should she be elected. Which brings me back to physician counseling. We can start by counseling Donald Trump's doctor to tell him to bow out of the race for the good of the Republican Party and the country, and go back to being a harmless reality show star.