As I began to draft this foreword in late August of 2019, it became apparent that the month ended as it began, with mass shootings in the USA. In the time it has taken for this article to appear in print, global social media platforms reported dozens of preventable tragic deaths and injuries; numbers that currently greatly exceed the combat deaths in Iraq and Afghanistan! In many ways, August was a month no different from other months in the USA, where violence is endemic, and reports of death by gun are daily events in many communities.
After decades of repeated mass shootings, we collectively cry for leadership to emerge and act, yet with each mass event, we only see elected officials, expert in their respective non-scientific, partisan scripts, resorting to the usual divisive nonproductive self-serving rhetoric or evasiveness. Meanwhile, the world looked at us in awe as to how the continued carnage could be tolerated in the world’s greatest democracy that holds itself out to be the protector of its citizens and the promulgator of best practices in science technology and policy.
Thus, it is fitting that my fellow surgical and medical colleagues, law enforcement officers, nurses, and public health researchers have offered me the privilege of writing the summation to this very timely nonpartisan and much needed scientific publication about the prevention of needless injury and death from guns. In this edition, you will find different perspectives from health care providers and public health officials, that will serve not only to inform about the many aspects of gun violence but also to highlight the need for all of us to address this public health emergency. Specifically, this collection of essays is not a call for gun control, but rather a Surgeon General and his colleagues advocating for a “call to action” for harm reduction by all options to mitigate and eventually prevent the ever-growing US epidemic of gun-related injury and death.
In my lifetime, I have had six decades of experience on both sides of the gun and have been wounded several times by gunfire; beginning as a US Army Special Forces medical and weapons specialist in combat, a police officer, firearms and tactics instructor, SWAT team leader, and a detective including homicide duty. The “tools” of my trades necessitate many types of weapons to be used judiciously as proscribed in law and taught in training. In addition, our competency was independently assessed on a regular basis to ensure safety, accuracy, and thorough understanding of the risks and benefits of all firearms used.
On the “other side of the gun” as a combat medic, paramedic, registered nurse, EMS director, and trauma surgeon, I have seen and treated the extraordinary and devastating physical and psychological wounds from gunfire while having taught gun safety in numerous programs. For over half a century, I have lived on both sides of the gun, which has provided me unique insights into the safe use and abuse of guns. If used appropriately, guns have the potential to achieve a military objective or protect a person or community while justifiably ending a potentially lethal threat. However, as we have increasingly witnessed, if used in an unintended manner, the gun can be a weapon of mass destruction and devastation.
As a police officer like Alex Eastman and colleagues (https://doi.org/10.1007/s40719-020-00186-7) and as a soldier, I had an immense responsibility to use lethal force when justified. Often, with only a second or less to make that decision and realizing that I would be held accountable, by law, by my peers, by the press, and the public. Similarly, as a trauma surgeon like Dr. Campbell and his co-authors (https://doi.org/10.1007/s40719-020-00188-5) and many of others in this profession who have seen the daily destruction of gun violence, I had tools like a scalpel and other technology and drugs that could be lifesaving if used correctly but lethal if not used as intended when medically and or surgically justified.
And, like the gun as a tool, the use of the scalpel and associated medical technology required specific training and third-party unbiased competency assessment before we were given the privilege to use for public benefit.
Whether for military, law enforcement, or civilian personal use, guns are a part of our society and it is our responsibility to ensure that as we respect the rights of lawful gun owners, we also exercise all options to keep society safe. Faced with the difficult task of bridging the chasm of extreme opinions, Drs. Stewart, Kuhls, and Bulger share their work on consensus building within the American College of Surgeons (https://doi.org/10.1007/s40719-020-00190-x). Drs. Dicker and Bonne discuss the importance of hospital- and community-based Violence Intervention Programs and the role that they may play in mitigating interpersonal violence (https://doi.org/10.1007/s40719-020-00184-9).
Firearm ownership in the USA is by far the highest of any country in the world. US gun ownership rate is up to six times higher than the average among wealthy nations of the Organization of Economic Cooperation and Development (OECD). Dr. Darzi and colleagues provide an international perspective on gun violence and outline the global concerns of gun violence and share their perspective from Great Britain (https://doi.org/10.1007/s40719-020-00189-4). In one section, the authors raise the issue of gun trafficking from the USA to other countries. Could it be that the complex issue of migration from countries in Central and South America is in part be due to an exodus from gun violence that is fed by a pipeline of weapons that originate in the USA?
Perplexingly, we are often not safer and frequently lead the world in gun-related suicides, homicides, and accidental deaths. This is not to suggest a cause and effect relationship but rather to point out that, with nearly 40 thousand US gun-related deaths and thousands more injured expected this year, the case is clearly made that this is a public health epidemic, an epidemic that needlessly adds billions of dollars to the preventable US disease and economic burden, immeasurable suffering to those families affected and a sense of uncertainty and fear in our citizenry.
Arguing about Second Amendment rights, physicians not “staying in their lane” or defining this solely as a mental health problem is senseless and uninformed. The proximate causes of this epidemic are complex and multifactorial and will require those of us with knowledge of this space to contribute to a scientifically informed dialog that protects our citizens and the lawful rights of gun owners. Unfortunately, the federal action in 1996 to stop funding CDC research on firearm injury has robbed us of valuable time where we could have studied and clarified many of the questions that still confound us today. In addition, aggregating epidemiologic research data over time with the use of machine learning and predictive analytics will eventually provide us additional scientific direction to inform our needed policies (https://doi.org/10.1007/s40719-020-00187-6 and https://doi.org/10.1007/s40719-019-00174-6). Previously, when our nation has been confronted by large public health challenges, we have acted decisively to protect the public through policy or regulation. Examples would include, but not be limited to, highway deaths, speed limits and seat belts, helmet laws for motorcycles and children on bicycles, primary and secondhand smoke, grounding unsafe aircraft until the problem is clearly defined and fixed, and recall of unsafe food or drugs. Drs. Hemenway’s group at the Harvard School of Public Health has been working on mitigating gun violence using a public health approach for years. He and others have been driven to better understand the determinants of firearm injury. In their sections, Dr. Hemenway and Dr. Joseph have outlined the scope of the gun violence problem as we know it to exist today and offer examples of research that is being done to better identify practical solutions to this very important and complex issue. Guns have been an integral part of US history in both positive, and more recently, negative ways. Drs. Hemenway, Joseph, and their co-authors present an overview on the scope of the public health issue of gun violence and the impediments to research that detract from our understanding of what interventions may work better than others (https://doi.org/10.1007/s40719-020-00182-x and https://doi.org/10.1007/s40719-020-00185-8).
In addition, we prospectively regulate activities that require skill, judgment, and safety, such as flying a plane, being a paramedic, physician, or a police officer and driving a car. For example, at sixteen, we do not just give the keys to a teenage child and wish them good luck. The vehicle, if driven safely, is a wonderful tool and privilege in the transition to adulthood. However, if used indiscriminately, the car can become a weapon of mass destruction just like a gun. Therefore, every state requires appropriate driver education and training leading to licensure after certification by an independent third party. Also, the privilege of a driver’s license is denied if your background indicates significant risk or your actions while driving place society in jeopardy.
Many questions legitimately arise based on the scientific public health approach to numerous societal challenges, including guns. Examples would include, but not be limited to, why then do states allow gun purchases without any training and certification of competence? Why do we not mandate comprehensive background checks to ensure that only “appropriate” persons are given the privilege of gun ownership? In fact, the public, in a bipartisan manner, is overwhelmingly supportive of this concept but leadership fails to act. Why do some states allow “concealed carry” without evidence of competency? Certainly, an armed citizen without training or demonstrated knowledge of firearm safety and competency could arguably be construed as a societal risk just like a person driving a car without training or licensure or a surgeon wielding a scalpel without training or competency certification.
Many have continued to argue that simply arming more citizens would make our communities safer. Respectfully I would disagree for I clearly understand the significant training and education required to safely use a gun in defense or offense. The training of a police officer and or a soldier takes months of comprehensive practice during the day and night and in simple to complex tactical situations to ensure competencies in safety, accuracy, target acquisition, and discrimination. Why would we expect that the average citizen, like an elementary school teacher or a business person, would be competent when given a gun and then expected to act proficiently in a complex tactical situation like an active shooter or witnessing an armed robbery? On the other hand, we have those who want to disarm all but police and military for they argue society would be safer and others who advocate for a ban on “assault” weapons and no large capacity magazines. Some of these ideas may have merit but all are expressing their respective intuitive non-scientific solutions supported by anecdotes which align more with their preconceived biases or political opinions but fail to clearly address the known risk factors and many other factors not yet elucidated and requiring research.
Our nation is now at a pivotal moment in history. A sense of loss infuriates and scares us. We live in a post 9/11 world where partisanship defines us, world economies and governments are being tested, 18 years of war continues, natural and manmade disasters challenge us, and domestic terrorism and mass killings have become the norm. Our previous sanctuaries of churches and schools are no longer safe havens and children in schools are trained in immediate action drills in the event of an active shooter. No surprise that stress and mental health problems are plaguing us as well.
The invention of gunpowder by the Chinese in the ninth century gave rise to its use centuries later in guns and for explosives. In the original 13 colonies and the expanding USA, guns were owned by most people for personal protection and as members of militias and the military. In fact, the first US legislation memorializing gun ownership was in 1791 in the 2nd Amendment of the Bill of Rights. To this day, the true meaning and intent of that legislation is still contested. The first piece of national gun control legislation was enacted in 1934. The National Firearms Act was primarily directed at gangland crimes. This was followed by the National Firearms Act of 1938 and many other legislative acts, which followed over the years that provided authorities to the federal government and attempted to define who should own guns and how and who should regulate guns. The debate continues today in interpretation of the 2nd Amendment and the rights of the individual, the state, and the federal government and their respective authorities. Our nation is now a patchwork of varying and confusing gun rules and regulations across 50 states. Although there have been many reported cases of mass violence with guns over the twentieth century, the case often recounted as the first civilian mass shooting was the Unruh shooting of 1949 in Camden, N.J., where 13 people were killed, including section author, Robin Cogan’s family members. Since that time, there have been thousands of mass shootings in the USA. In fact, the USA leads the world in mass shootings. The actual numbers are often disputed since different organizations characterize mass shootings with different criteria. Many use 4 or more victims as a benchmark.
Other often-cited mass shootings include the Texas tower incident in 1966 where 18 were killed and another seminal event, the Columbine High School shooting in 1999 where 13 were killed and 20 wounded. Both devastating, but the former was in the pre-digital age and the public still believed that this was an aberrancy and could not happen in their community. Columbine was transmitted real-time over-all media platforms as if it were an action movie playing out before our eyes. This event was a wakeup call for our nation and its first responders. From new tactical protocols first described as “extraordinary deployment,” to the inclusion of tactical emergency support (TEMS), and rescue teams and the evolution to the concept of active shooter(s), our first responder community realized that the rapid inclusion of an innovative approach to these new gun threats was essential to protect society.
Unfortunately, whether via a “copycat” theory and/or other yet to be researched and described phenomena, the death, mutilation, and devastation caused by active shooter(s) continue today with increased frequency, seemingly on an almost regular basis.
It should be noted, paradoxically, whereas gun-related mass shootings generally account for less than 1% of all handgun deaths, the acute mass devastation attracts significant global media in a 24/7 news cycle as opposed to individual suicides, homicides, and accidental shootings which collectively account for most gun-related deaths. In addition, although the focus of this call to action is guns, it is noteworthy that there have also been many non-gun-related mass killings from knives, explosives, and weaponized automobiles and planes in this era of domestic terrorism.
My health care colleagues are generally not gun experts, but they are the experts in dealing with the consequences of the intended and unintended use of guns. Some physicians, like Dr. Mike Hirsh, have taken approaches to engage the community in unique ways by operationalizing gun buyback programs that have removed thousands of guns from homes where they are no longer wanted as described here in https://doi.org/10.1007/s40719-019-00180-8. In addition, front-line nurses like school nurse Robin Cogan and co-authors discuss the impact of gun violence within schools from their perspectives. Their observations and skills that are outlined in https://doi.org/10.1007/s40719-019-00179-1 are crucial to ensuring the health and safety of students, staff, and faculty within schools and the surrounding community. These school nurses are critical to the design and implementation of these programs that keep students safe and ready to learn.
Leaders are responsible for the destiny of others. As physician and nursing leaders, it is our collective responsibility to address this epidemic as we do all other epidemics, through the best science available and the future research that must be done to protect the society. The physical and psychological devastation that ensues from gun violence is nonpartisan and is preventable. However, there is no single solution. This will be an evolving process that will incrementally identify the many variables that contribute to the loss of our national safety and security. We have done well as a nation in developing new and innovative structural approaches to the response, mitigation, and recovery from mass killings. However, the time has come for us to be equally aggressive in the public health approach of preventing these devastating events that rob us of our humanity, civility, and our freedoms.
Failure or continued nonproductive partisan disruption is not an option, for the public we have the privilege to serve is depending on us.
Conflict of Interest
The author declares he has no undisclosed conflicts of interest.
Richard Carmona is a 17th Surgeon General of the United States
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Carmona, R. Life on Both Sides of the Gun: a Surgeon General’s Call to Action. Curr Trauma Rep (2020). https://doi.org/10.1007/s40719-020-00191-w