Tendrils of Hope in the Gun Epidemic: A Public Health of Consequence, November 2019

We are writing this editorial just days after mass shootings in Dayton, Ohio, and El Paso, Texas, resulted in 31 people dead and more than 50 people injured. The US national conversation has been, over the past 48 hours, ablaze with commentary about the need for policy efforts that reduce the consequences of gun violence. And guns have come, once again, to dominate the political conversation. In some ways this cycle is familiar. Although firearm mortality in the United States has been roughly at the same level for nearly 20 years (although there has been an increase in the past couple of years), attention to the issue has crystallized around mass shootings, particularly since the Newtown, Connecticut, shootings in 2012 when 26 students were killed at Sandy Hook Elementary School. The Parkland, Florida, shooting in 2018, when 17 students were killed at Marjory Stoneman Douglas High School, catapulted a new generation of student-led activism to the fore, making gun violence part of the ongoing national conversation. Although mass shootings account for fewer than 2% of all the gun-related fatalities in the United States, they have served to focus public attention in a way that the more than 36 000 annual deaths from firearms, most from suicide, have not.

In their response to gun violence, public health practice and academic public health have lagged substantially behind in their study of one of the defining epidemics of our time.¹ Public health practice has been hampered in no small part by political forces. The Dickey Amendment, attached to an omnibus spending bill in 1996, prohibited the Centers for Disease Control and Prevention (CDC) from spending money “to advocate or promote gun control.” This amendment had a chilling effect in multiple ways, but in particular it served notice to public health practice not to engage in work that aimed to limit access to or availability of guns.

Public health agencies at the municipal, state, and federal levels were all appropriately concerned with taking on an issue that could result in substantial political opposition and potentially a cut in funding to other areas of work. This climate of hesitation to take on issues related to firearms spread to research funding, with neither the CDC nor the National Institutes of Health (NIH) making substantial funds available for research for approximately two decades.² A direct result of this was a dramatically lower research engagement with firearms and their consequences than would have been commensurate with the scope of morbidity and mortality that accompany guns in the United States.³

TURNING THE TIDE

And now perhaps the tide is turning. As we noted more than a year ago, there was a decisive change in the number of articles published on firearms as a proportion of all articles published in public health in 2017.⁴ This coinciding with the broader public conversation on firearm violence when the issue had risen to occupy a place at the forefront of all major media and was fueled by an increase in funding for the issue from federal funders (e.g., the NIH) and private funders. This turn of events was heartening and, as suggested then, the key question “seem[ed] to be how do we collectively sustain this increase in firearm-related science to create a new generation of scholarship that elucidates the public debate?”^4(p859) Fortunately, as evidenced by work in this month’s issue of AJPH, we are doing just that.

In this issue of AJPH, Matthay et al. (p. 1605) evaluate the Operation Peacemaker Fellowship, a firearm violence–prevention program implemented in Richmond, California.⁴ Operation Peacemaker Fellowship is an interesting program that emerged from the public sector in response to the unremitting pressure of gun violence. The program offered tailored mentorship, case management, cognitive behavioral therapy, and internship opportunities, among other efforts to help community-dwelling individuals who were believed to be responsible for violence in the community. Although previous work has suggested that the program was associated with reductions in violence,⁵ there has been no rigorous evaluation of the program. Thus it is considered a natural experiment that used appropriate methods to take into account alternate explanations, such as changing socioeconomic trends over its period of implementation.

The article of Matthay et al. rectifies these shortcomings and shows that Operation Peacemaker was indeed associated with reductions in firearm violence, with an approximate 50% decrease in crimes and deaths and hospital visits annually and, perhaps unexpectedly, an annual small increase in nonfirearm violence. Importantly, Matthay et al. add to the literature about approaches that can be adopted to minimize the consequences of guns and do so applying state-of-the-science methods, building an evidence base that can inform the public discussion. That a new generation of scholars is doing this work is even more encouraging and is another sign that a growing body of scientists will lead to more science in the field.

TIME TO ACT

Challenges with firearm violence research include that we need more scholarship in the field and that we need to know enough to guide action. Public health action must almost always act in the absence of imperfect information, and in the area of guns we know plenty⁶ to move us past the current state of policy inaction. And yet, growing population health science provides tendrils of hope that we are at a crucial time in the field, which was first seen in 2017 and has now been sustained throughout the past couple of years, portending a future when we have abundant science that can inform an engaged public health practice and when the US firearm epidemic starts to beat a retreat.