When James Mercy, MD, joined the Centers for Disease Control and Prevention (CDC) more than 30 years ago, he was assigned to work on violence prevention. At the time, the program had a limited budget and two or three full-time employees.
Likening the early days to working with one hand tied behind his back, Mercy, who now serves as Director of the CDC’s Division of Violence Prevention, said that in the beginning the words violence and prevention were rarely used in the same sentence. And while the terms have since become common together, progress in preventing violence has been inhibited by decades of neglecting research and a longstanding lack of adequate policies necessary to more effectively understand and address gun violence and the people impacted by it every day in the U.S.
As a result, the epidemic has only grown worse. Highly-covered gun incidents enter the national spotlight but many other tragedies garner less attention. Nine U.S. cities, in fact, broke homicide records last year and nearly all of the major cities that reported data experienced an increase in shootings as well. With at least nine shootings already in 2022, spanning both coasts and several states around the nation, violence does not appear to be easing in the new year.
Indeed, impactful improvements will not happen in the short-term, and health care executives face considerable work in addressing the issue. Changes regarding research into gun violence and federal funding to support those efforts are at the very least opening new dialogues about how to better understand gun violence as step toward learning how to prevent it.
Congress in December of 2019, for instance, allocated $25 million divided evenly by the CDC and the National Institutes of Health to fund research projects examining ways to reduce deaths and injuries resulting from gun violence. Now, President Joseph R. Biden Jr.’s Build Back Better Act includes $5 billion to be used for community violence interventions — and while Build Back Better has yet to be passed into law, meaning Congress could change or reduce the $5 billion, the proposed legislation signals a marked increase in the potential for federal funds to address the uniquely American crisis.
“We are entering a new era in terms of the public’s understanding of gun violence and gun violence prevention,” said Fatimah Loren Dreier, Executive Director, Health Alliance for Violence Intervention during the Northwell Health Gun Violence Prevention Forum.
Gun violence, in fact, has become widely recognized within the health care sector as a public health problem of epidemic proportions.
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“This is not just a gun crisis, it’s a public health crisis.” said Susan Rice, Domestic Policy Advisor at the White House. “Community violence intervention programs have been shown to reduce violence by 60 percent.”
But how can CEOs lead impactful changes in the gun violence crisis and, as Rice called for, integrate violence prevention into overall medical and health care strategies?
To inform a way forward, Northwell Health hosted a virtual event, which featured Dreier, Mercy, Rice and other experts. During the webcast, speakers discussed steps that health CEOs can take today to begin the journey to reducing gun violence, including:
- Applying lessons learned from other epidemics
- Creating a research-based roadmap to drive change
- Educating the workforce and the community
- Partnering with community-based organizations
- Advocating that more CEOs join the effort
Applying lessons learned from other epidemics
Firearm homicide rates increased by more than 30 percent across the country between 2019 and 2020, according to the Pew Research Center, which noted that is the most significant one-year increase in more than a century.
“In the midst of the firearm epidemic, we need to take action and not be limited to perfect science,” said CDC’s Mercy.
Much the way the U.S. has handled COVID, however imperfectly that has been, and adjusted as clinical trials, research and science evolved, the gun violence epidemic requires a similar response.
“Violence is a behavior pattern that works like infectious disease,” said Joseph Sakran, MD, Director of Emergency General Surgery and Associate Chief in Johns Hopkins Hospital’s Division of Acute Care Surgery. “It’s possible to slow the spread of violence in the community but that requires a comprehensive approach.”
As is the case with COVID-19 and other viral outbreaks, there are even more non-fatal injuries than deaths. Sakran said that relative to gun violence the estimated 2-3 non-fatal incidents per death is a conservative number. To that end, he advised that health care leaders consider that the best medical treatment is often prevention and work toward establishing a system that makes it less likely for people to be injured or killed because of guns in the first place.
Developing a research-based roadmap to drive change
Beyond the emergency of responding urgently to the epidemic is the longer-term necessity of understanding the problem’s root causes.
“There’s a real opportunity to engage in dialogue through research. It’s going to take a lot of stakeholder engagement to really advance an agenda and actually encourage people to stay engaged,” Dreier said.
CDC’s Mercy added that policy is a clear gap and need. One example that is working is in 2016 the Utah State Legislature passed House Bill 440, Suicide Prevention and Gun Data Study which called for research into gun violence and suicidality. In Utah, 85 percent of gun deaths are suicides and nationally 60 percent of gun deaths are suicides.
“The work that came out of that provided some clarity and some common purpose, which is great,” said Marc Harrison, MD, CEO, Intermountain. “Maybe the most important thing is that it created a platform for dialogue. and it activated people from all over the political spectrum in the interest of keeping our neighbors safe.”
Northwell Health CEO Michael Dowling said the work should begin with outlining the basic research needs and actions that if accomplished would make a marked difference by reducing injuries and deaths that result from gun violence, and then use those to inform a strategy for moving forward.
“We need to develop a roadmap,” Dowling said. “We can talk about what we’re doing but we need to develop a consistent roadmap that we can all follow.”
Educating the workforce and the community
Frontline health care workers are not necessarily trained or prepared to have difficult conversations about gun violence. Driving factors include whether people own firearms themselves, grew up in a house with guns and gun-related politics as well as the socio-geographic region where they live. The reality that gun availability and control are politically polarizing matters in the U.S. only complicates the issue.
“It’s similar to situations we have around smoking cessation and so forth,” Sakran said. To educate its workforce, Johns Hopkins Hospital has developed a toolkit and a process to empower health care workers to be able to engage in sensitive conversations about gun violence.
With funding from the NIH, Northwell established a screening program across all of its emergency departments to ask incoming patients questions about potential dangers with regard to gun violence and whether there are guns in their home to both understand what its population is experiencing and to educate Northwell’s 70,000 employees.
“The more they know about what the problems are, how we can help and how they can promote that education, all of that will make a huge, huge difference,” Dowling said. He added that Northwell is also working with law enforcement to educate the community. “The more education we can do in the schools, with the students, with the parents and to provide ongoing collaborative support, the bigger difference it will make.”
Partnering with community-based organizations
As with many societal issues, leading health care CEOs are recognizing the necessity of joining forces with outside organizations to accomplish more than is possible when operating individually.
“There’s no one person or organization that has all the answers to this problem,” Sakran said. “It requires a multi-faceted multi-disciplinary approach and that means there are a variety of solutions to tackle the different aspects of gun violence.”
Intermountain, for its part, is working in public-private partnerships with organizations and people with already-established credibility to prepare them to work with individuals to make the community safe. Harrison said that one of the most effective tactics Intermountain has deployed in conjunction with primary care physicians, community physicians and community groups is to distribute some 30,000 trigger locks.
“We know that impulsivity is a big issue, particularly when it comes to self-harm, but also in harming other people. Making things just a little more difficult in the form of trigger locks can have enormous impact in terms of outcomes,” Harrison said.
All efforts need to be integrated across sectors. “When public health works well it’s not just the medical system working alone,” CDC’s Mercy said. “It’s public health, health departments, medicine, criminal justice, housing, media, education, all working together on an issue. When we address COVID, when we address HIV, any major health problem, that’s what we strive to achieve and that’s an important contribution.”
All too often, however, cities and states operate with siloed institutions such that the health care system is not effectively aligned with the public health department, law enforcement and other relevant organizations.
“We really need to figure out how to break down these barriers so we can all work together in a cohesive and comprehensive manner to address this issue that really has no lines,” Sakran said.
Advocating that more CEOs join the effort
After the August 2019 shootings in El Paso, Texas and Dayton, Ohio, Dowling began reaching out to CEOs of other health systems to figure out how to tackle the problem head-on. The initial response was not positive as some leaders contended that they need to take care of illness, treat sick people, and not be involved in such a contentious issue.
In one instance, he was discussing the subject with the leaders of approximately 50 hospitals, some of whom reacted by saying that key executives and board members are either gun owners or very conservative when it comes to the issue of gun control, and starting such initiatives would quickly lead to arguments about Second Amendment rights
“This is about gun safety. This is about protection. This is about prevention. Getting that message across has engaged more and more people,” Dowling said. “Over the last couple of years, we now have hundreds of local health care organizations that have joined a collaborative that we initiated. The majority of Americans, including the majority of gun owners, want gun safety.”
Taking a similar mindset, Intermountain partnered with the Utah Shooting Sports Council and other community groups to help people increase safety in their homes — an alignment that Harrison said he initially considered unlikely.
“When I first heard about this potential partnership, I was not terribly optimistic, but guess what, these are good people, and we have more in common than we have different between us. We’ve been quite successful,” Harrison said. “Our country is polarized right now and people are angry at each other a lot and they want to back each other into corners and take very binary approaches and it’s just not practical. Vilifying and demonizing your neighbors doesn’t take you very far. At Intermountain, we’ve really worked hard to build bridges, not pick fights.”
Gun violence as a public health crisis is a daunting problem and, while more resources are becoming available present reasons to be skeptically optimistic, change will not happen quickly. But as a public health issue there is a growing consensus that preventing violence is now an obligation and a responsibility for large health care organizations and the CEOs who lead them.
Succeeding will require managing gun violence with the same rigor applied to other epidemics, developing strategies to make change where possible, educating populations about the issue, partnering to increase resources and reaching and identifying commonalities with other people and organizations to meaningfully change today’s conditions.
“The journey we’re on is not a sprint, it’s a marathon and it requires us all to be resilient, to hang in there, not to slow down but to take a long view and to be eternally optimistic,” Northwell’s Dowling said. “It will get better. It will take a long time so we have to persevere and be optimistic. All the collective activity and partnerships will bear positive fruit — I’m absolutely convinced of that.”