AAEM Committees

AAEM and Firearms Injury Prevention

by William Durston, MD FAAEM

Firearms violence is at epidemic levels in the United States. In the United States in 1997, there were over 32,000 fatal shootings and an estimated 64,000-100,000 non-fatal gunshot injuries.^1,2,3 By comparison, there were approximately 3,000 deaths due to polio in the United States at the height of the polio epidemic in 1952. The rate of firearms deaths in the United States is comparable to the rate of deaths due to AIDS.¹ By 1991, the annual number of firearms-related deaths exceeded the number of deaths due to motor vehicle accidents in seven states, including California, New York, and Texas.⁴ It is estimated that the annual cost of medical treatment of gunshot injuries in the United States is $2.3-4 billion.^5,6 The overall cost to society of firearms-related injuries in the United States has been estimated to be $112 billion annually.⁷

Firearms-related deaths and injuries are particularly rampant in pediatrics patients and young adults in this country. There have been multiple studies in the medical literature documenting the dramatic increase in pediatrics firearms injuries over the past four decades.^8,9,10,11,12 The rate of firearms-related deaths for U.S. children younger than 15 years of age is nearly 12 times greater than the rate in the other 25 leading industrialized nations of the world.^13,14 A child in the United States is currently far more likely to catch a bullet than to catch the measles.^3,15 The homicide rate for U.S. males ages 15-24 is more than ten times higher than in most other developed countries, with three quarters of homicides being committed by firearms in the U.S. while less than a third of homicides are committed by firearms in most other countries.¹⁶

The much higher rate of firearms violence in the United States as compared with all other industrialized countries corresponds with a much higher rate of firearms ownership in the U.S.^17,18,19 Within the United States, as well, the community rates of firearms violence generally parallel community rates of firearms ownership.^20,21,22 There are approximately 200 million privately-owned firearms in the Untied States.²³ It is estimated that 30-40% of adults keep firearms in their home.²⁴ Most persons who keep firearms at home cite personal protection as the reason for having guns.²⁵ In fact, however, multiple studies in the medical literature have shown that having a gun in the home substantially increases the chances of a household resident being shot and killed or injured.^{26,27,28,29,30,31} In one of these studies, it was found that for every time a gun in the home was used to kill an intruder, there were 43 firearms-related deaths of a household member.³⁰

Numerous physicians specialty associations, including the American College of Physicians,³² the American Academy of Family Physicians,³³ the American Academy of Pediatrics,³⁴ and the American College of Surgeons,³⁵ support a variety of measures to reduce firearms violence. In 1998, the American College of Emergency Physicians endorsed the Eastern Association of Surgery for Trauma position paper on violence in America.³⁶ The EAST position paper called for certain restrictions on private ownership of handguns and licensing and registration of all individual firearms, in addition to other measures to reduce overall violence.³⁷ To date, the American Academy of Emergency Medicine has not adopted a formal position with regard to firearms violence. Other cross-specialty physician organizations, including Physicians for Social Responsibility and Physicians for a Violence-Free Society, have been actively involved in firearms injury prevention. In addition, many lay organizations, including Handgun Control, Inc., The Center to Prevent Handgun Violence, and most recently, the Million Mom March (formerly the Bell Campaign), have actively promoted legislation and educational programs to reduce firearms violence.

How effective have these efforts been? From 1993 to 1997, there was a 21% drop in overall firearms mortality in the U.S.³ Some experts attribute this decline to gun control measures such as the Brady Bill, passed in 1993, and to stiffer sentencing laws for criminals, while others believe that the drop in the firearms mortality rate may be due merely to the booming U.S. economy and the associated overall decrease in crime. Though the recent decline in firearms fatalities in the U.S. gives reason for hope, firearms violence is still epidemic. For the firearms fatality rate in the United States to drop to the average level for the other 35 leading economic nations of the world, there would have to be an 88% decline from 1993 levels.³⁸ For the U.S. rate to drop to the level in England, where private possession of handguns is prohibited outside of sporting and hunting clubs, the U.S. rate would have to drop 97% from 1993 levels.

A significant obstacle to curbing the firearms epidemic in the United States is the pro-gun lobby. In the 1950s, there was no organization lobbying to protect the right of Americans to carry the polio virus. When the polio outbreak occurred, the medical community worked rapidly in conjunction with the government and the public to develop and disseminate a vaccine which effectively eradicated the virus and stopped the epidemic. In the United States today, the well-funded and highly political National Rifle Association lobbies against even the most moderate gun control measures. The influence of the pro-gun lobby in the United States may in part explain why the response of U.S. legislators to the rash of recent firearms tragedies in this country has been so limited in comparison with the responses to similar events in other countries.

In Canada, after the massacre of 14 women at Montreal's L'Ecole Polytechnique in 1989, the Canadian government, with strong support from the Canadian Association of Emergency Physicians, passed comprehensive gun control legislation, including mandatory registration of all firearms and controls on sales of ammunition.³⁹ In Australia, after a man with a semiautomatic rifle murdered 35 people in the tourist town of Port Arthur in April of 1996, the Australian government moved quickly to ban semiautomatic weapons, forcing the surrender of 640,000 firearms to authorities.⁴⁰ In Britain, after the massacre of 16 schoolchildren and their teacher in a Scottish school, the conservative-led government moved to bar personal possession of handguns altogether. (The number of persons murdered with handguns in 1995 in Britain was 30, compared with 9,390 in the same year in the United States.)⁴¹ After two Columbine High School students shot and killed 12 other students and a teacher and wounded 23 others before killing themselves in Colorado in April of 1999, the Clinton administration introduced legislation to require background checks before purchases of guns at "gun shows," closing a loophole in the Brady Bill. More than a year later, Congress continues to debate this same measure, and no new federal gun control legislation has been passed.

There are proposals for new legislation in progress, including laws to require licensing and registration of all firearms, but these proposals seem unlikely to succeed in the foreseeable future unless there is a dramatic shift in political power. Besides treating those victims of firearm violence who are not pronounced dead at the scene, what should we emergency physicians be doing with regard to firearms violence epidemic?

Many of us believe that it is time for emergency physicians to become more active in the effort to curb the epidemic of firearms violence in our country. Emergency physicians are uniquely qualified for this role. We have first-hand experience in treating the victims of firearms violence, and we understand the seriousness of the epidemic. We have close ties with other medical specialties, with law enforcement, with public health, and with legislators. The American Academy of Emergency Medicine, in particular, is well-suited to assume a leading role in these efforts. As noted above, there is abundant evidence in the medical literature demonstrating that firearms ownership by private citizens increases rather than decreases the risk of firearms-related injuries and deaths. Nevertheless, gun control remains an extremely controversial topic, even within the medical community. AAEM has not shied away from other controversial issues, such as entrepreneurship and board certification in Emergency Medicine. In a similar fashion, I believe that AAEM should take the moral high ground and act rapidly and decisively to reduce firearms violence. Specifically, I would propose that AAEM take the following steps:

1. Adopt a strong position statement on firearms injury prevention, similar to that of the American Academy of Pediatrics, which calls for firearms regulation, to include bans on private ownership of handguns, semiautomatic, and automatic weapons as the most effective way to reduce firearms-related injuries.

2. Establish a dedicated Firearms Injury Prevention Fund.

3. Promote the education of other physicians, the lay public, and state and federal legislators regarding the seriousness of the firearms violence epidemic and the risks of private ownership of firearms.

4. Foster legislation to reduce firearms violence.

5. Develop cooperative relationships with other physician and lay organizations dedicated to reducing firearms violence.

In its short period of existence, AAEM has shown that a relatively small group of dedicated physicians can have a substantial impact on the practice of Emergency Medicine. I believe that AAEM can also have a substantial impact in curbing the firearms violence epidemic, and that doing so could become one of AAEM's greatest achievements. AAEM president Robert McNamara has asked me to head an AAEM Task Force on Firearm Injury Prevention that is being charged with preparing a position statement for review and possible endorsement by the AAEM Board of Directors. The Task Force will also be asked to make other recommendations to the Board on this important issue. If you are interested in participating in this Task Force, please e-mail me at bdurston@aol.com.

References

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