Issues in Depth

Gun fight

Vital Signs » Winter 2015
Gun graphic

A public health approach to battling gun violence

Kevin Purcell’s academic interest in gun violence had its roots in the very visceral reaction he had to finding himself looking down the barrel of a handgun.

Now a third-year medical student at Wright State University’s Boonshoft School of Medicine, the Brooklyn-born Purcell, 27, tried to break up a scuffle at a college party in New York state some years ago when one of the revelers pointed a gun at his head.

Although the gunman ultimately lowered the weapon and Purcell was unharmed, “My life went before my eyes in the blink of a second,” he said.

Purcell is one of many in the medical school community and beyond who are taking a public health approach to the seemingly intractable problem of gun violence in the United States. They say the nation needs to get beyond heated political arguments about gun control and pursue multiple strategies compatible with the Second Amendment to bring down frustratingly high rates of firearm deaths and injuries.

Outbreak in Montgomery County

More than 32,000 people die from gunshot wounds annually in the United States, two-thirds of them suicides, according to the Centers for Disease Control and Prevention. About 67,000 suffer nonfatal gunshot injuries, more than half of them requiring hospitalizations. While studies show gun violence has declined significantly since the early 1990s, the journal Preventive Medicine reported in a 2015 article that between 2000 and 2012, “firearm suicides increased and nonfatal firearm assaults increased to their highest level since 1995.”

Locally in Montgomery County, the use of firearms in homicides leaped from 52.1 percent in 2000 to 73.5 percent in 2011, an increase of more than 40 percent, according to a 2013 analysis of suicide and homicide deaths coauthored by Sara J. Paton, Ph.D., director of the Master of Public Health Program.

“You can almost consider gun violence as a disease, and it’s going up,” Paton said. “We’re having an outbreak.”

Solutions elusive
I have had instances where people come in (with gunshot wounds) and you x-ray them and you find other bullets

Experts acknowledge solutions have been depressingly elusive, even in the wake of such high-profile mass shootings as the December 2012 bloodbath at Sandy Hook Elementary School in Newtown, Connecticut, in which a gunman killed 20 children and six adults. There were at least 142 school shootings between Sandy Hook and the October 1, 2015, shooting spree at Umpqua Community College in Roseburg, Oregon, that left 10 dead, according to the nonprofit Everytown For Gun Safety.

Gun violence continued to be a major issue as 2015 drew to a close with mass shootings, including the deadly November 27 attack on a Planned Parenthood clinic in Colorado that left three dead and the December 2 rampage in San Bernardino that killed 14.

“People are just deadlocked,” said Peter Ekeh, M.D., professor of surgery and medical director of the trauma program at Miami Valley Hospital in Dayton. “You see two camps. You see the people who say the right to carry arms is part of the American DNA, and you have the camp that wants to limit access to guns. I think the answer is somewhere in the middle. I’ve heard all the sides of the issue, and I think every one has some validity.”

Limiting access to guns is difficult, he noted, not only because of Supreme Court interpretations of Second Amendment rights, but because the nation is already so flooded with firearms. There are an estimated 300 million guns in private hands in America, so even if the manufacture of new weapons stopped tomorrow, guns would continue to present problems long into the future, he said.

“We have to live with that,” Ekeh said. “That’s the fact on the ground.”

Public health issue

Like others interviewed for this article, Ekeh believes gun violence can be reduced if health professionals use a multifaceted approach that not only focuses on guns, but the underlying causes of violence with an eye toward prevention.

“It should be dealt with as a public health issue,” he said. “At one point in this country, we had typhoid as a public health issue, smallpox, AIDS. The socioeconomic issues that push people toward violence need to be addressed.”

Miami Valley Hospital’s (MVH) Injury Prevention Center, headed by Ekeh, has been taking steps to do exactly that. One example: For the last several years, the center has sponsored a program called Hope in the Valley in conjunction with Montgomery County Juvenile Court. Under the program, which meets for two to three hours weekly for four weeks, troubled youth aged 12-15 learn alternatives to violence in an effort to “realign their lives,” Ekeh said.

A new program, which is to be launched in 2016, will make social services available to gunshot victims in a bid to keep them from being re-victimized. Some gunshot victims, Ekeh noted, are involved in activities that put them at risk of being shot, such as engaging in criminal enterprises or associating with gangs. He said he has treated the same people for gunshot wounds multiple times at MVH, and “I have had instances where people come in (with gunshot wounds), and you x-ray them, and you find other bullets” from earlier shootings.

The program will offer education, help with employment issues, and other services to gunshot victims.

“A lot of times, this is a teachable moment for them, when they have been shot,” Ekeh said.

bulletsA second chance at death

Medical student Purcell, who has worked in violence prevention and written a thesis on gun violence, agrees.

“When you save a gunshot victim, you don’t give them a second chance at life, you give them a second chance at death because you haven’t gotten to the root cause of the problem,” he said. “The physician’s job is to heal. Not just medically, but emotionally, spiritually. (In cases of repeated gunshot victimization) you’re telling me you didn’t do your job, because you fixed this person up and three months later he’s back in a trauma bed.” Mary C. McCarthy, M.D., Elizabeth Berry Gray Chair and professor of surgery, said it’s important to remember that not all gunshot victims occasioned their own injuries. Doctors should triage patients strictly on the severity of their injuries, not on any preconceived ideas about whether a victim had culpability in the shooting.

“I try not to find out,” she said. “I don’t want to know.”

In one of McCarthy’s first cases involving gun violence, when she was in medical school, an acquaintance who was employed by the Indiana hospital where she worked “came in one night while I was on call with a shotgun blast to the abdomen. He wasn’t the intended victim. He was just in the wrong place at the wrong time.” The man survived the shooting.

A few years later, McCarthy was a resident at Dallas’ Parkland Hospital, where President John F. Kennedy was treated after his mortal wounding on Dealey Plaza in 1963.

One day two decades later, McCarthy was present when medics brought in wounded police and civilians who had been involved in a “tremendous firefight” in the civilians’ home. It was believed the civilians were criminals who shot the cops as they raided the home, and there may have been a temptation to give top priority to the police officers even though their wounds were less severe, she said. As it turned out, the police raided the wrong home and the people in the house fired at the officers in self-defense.

“Information at the scene is rarely correct, so you don’t want to make a (treatment) decision based on that,” McCarthy said. “There’s always more to the story.”

Gunshot injuries more severe

Miami Valley’s trauma unit treats far more accidents (90 percent of its caseload) than penetrating trauma like gunshot and stab wounds. But gunshot wounds often are fatal, especially in cases of suicide.

According to Preventive Medicine, the fatality rate for suicide attempts involving guns is 85 percent, compared to 19 percent for assaults by firearm and 5 percent for unintentional firearm injuries.

The severity of injury is often greater with gunshot wounds than other types of traumatic injury, McCarthy said. “If you get stabbed, there’s a very localized injury. (A gunshot wound) is more extensive—and more lethal.”

She said she finds trauma care exciting and rewarding—and so do medical students. “Everybody wants to take care of trauma victims,” she said. “It’s very adrenalin-charged. A lot of students enjoy their rotation on the trauma service.” Some 20 percent of our general surgery residents go on to work in trauma and critical care, McCarthy said.

McCarthy, who founded the Injury Prevention Center in the mid-1990s, said people should contact authorities if they suspect a friend or relative may be prone to violence. “If they’re concerned, they need to tell somebody,” McCarthy said. “In so many of these active-shooter incidents, people know these people are having (psychiatric) problems. It doesn’t just come out of the blue. Trauma is a preventable disease.”

Also, “there’s just too many guns and too many assault weapons. I mean, how do assault weapons end up in the hands of disturbed children? I can’t say I’m opposed to guns, but there’s no place for assault weapons in a civilized society.”

Mass shootings capture headlines
It’s better to build strong kids than to repair broken men

While they make up only a sliver of the gun violence in America, random mass-shootings in public places like schools and movie theaters have captured headlines.

“There seems to be—and this is arguable— an increasing number of these incidents,” said Brian Springer, M.D., associate professor of emergency medicine and director of the tactical emergency medicine division in the Department of Emergency Medicine. In the latter role, Springer, who also is a commissioned law enforcement officer for Grandview Hospital, provides medical support for area police, particularly Special Weapons and Tactics teams. He is also an attending physician at Kettering Medical Center.

Active-shooter incidents can be headed off with better security at schools, more school resource officers, and better awareness and preparedness for all civilians, Springer said. Since the 1999 massacre at Colorado’s Columbine High School, there has been an increased emphasis on getting tactically equipped and trained medics into shooting scenes earlier to help the wounded.

“As far as prevention, that’s a tough one,” Springer said. “You’re dealing with not only disturbed minds but young minds, and that’s always been a problem.”

Police militarization has been a controversial topic in the wake of a wave of officer-involved shootings of unarmed people, particularly black men, and Springer acknowledged that some police departments are ill-trained and dazzled by getting the latest “tacti-cool” gadgets. He also acknowledged that police departments that invest the time and money to create SWAT teams are more likely to use them. “Obviously,” Springer said, “quality varies among them.”

But he said properly trained and equipped SWAT teams can manage a crime scene and “wait things out” so there’s a “safer resolution” to “not only enhance officer safety but also the safety of the public and even the suspect.”

On a day-to-day basis, law enforcement can have an increased impact on gun violence by stepping up gun-law enforcement, by mediating disputes between gangs, by having a more “visible presence at gun shows,” where background checks aren’t always required, and by “communicating with reputable (gun) dealers to make sure the law is being followed.”

Community options in dealing with violence

Ken Dahms, J.D., who teaches public health ethics and policy at the Center for Global Health, said communities still have options for dealing with gun violence, even if the Supreme Court has struck down gun control efforts.

“Obviously, there are some limitations that have been set by the Supreme Court, but there are lots of policy options remaining,” he said. Perhaps half of the annual firearms deaths in the U.S. could be prevented with policy changes, he said.

Universal background checks before any gun sale, significant controls on assault weapons, stronger efforts to keep guns out of the hands of people suffering from severe mental illness, along with increased crime watches and education in impacted communities are among those options, said Dahms and Paton. “Gag order” laws in some states that prohibit doctors from talking with their patients about gun violence also should be eliminated, Dahms said.

Epidemiologist Paton is working on a strategic plan for Montgomery County’s Family and Children First Council to find strategies to curb gun violence.

She noted that men tend to be most prone to using guns. Studies show middle-aged white men who commit suicide are most likely to use guns, while young black men are overrepresented as victims of firearm homicides.

Paton said mental health services don’t get the same attention, or funding, as physical health services, and increasing access could reduce suicide. But she acknowledged that funding is tight for all types of social and public-health programming that might make an impact.

“There’s not a lot of extra funds going around in general,” Paton said. “Budgets are tight for public health and mental health services.”

High cost of gun violence

But the cost of maintaining the status quo also is high. Between 2010 and 2012, firearms deaths and injuries totaled $48 billion in medical and work-loss costs, Preventive Medicine said.

Mother Jones magazine sets the cost much higher. In an April 2015 report, the magazine said its analysis found the annual cost of gun violence in the U.S. is $229 billion, higher than the cost of obesity and nearly the cost of the Medicaid program. It said direct costs— including medical costs and incarceration— total $8.6 billion, while indirect costs like lost income, losses to employers, and impact on quality of life add up to $221 billion.

bullet“People don’t understand the cost of violence,” Purcell said. “They don’t understand the strain it places on society.”

Social programs do get results, he said. He worked with troubled youth in Brooklyn in an anti-violence program that led to some getting jobs and furthering their educations.

“It’s better to build strong kids than to repair broken men,” he said.

Purcell said he realizes that gunshot victims can be among the most difficult and hostile patients, but he urged doctors to look beyond the attitude and find ways to not only treat their wounds but help them heal their lives.

“Medicine is supposed to be about compassion,” he said. “Well, that’s compassion at its finest.”

—Tom Beyerlein

Last edited on 04/29/2016.