Eastern Association for the Surgery of Trauma Statement on Structural Racism, and the Deaths of George Floyd, Ahmaud Arbery, and Breonna Taylor

The Eastern Association for the Surgery of Trauma (EAST) is a scientific society whose mission is to advance the surgery of trauma, to expand knowledge of how to prevent injury, and manage the injured. As doctors that seek to treat and prevent trauma, it is impossible to ignore the unequal burden of violent deaths experienced by African Americans, and deaths, including those of Mr. Ahmaud Arbery, Ms. Breonna Taylor, and Mr. George Floyd, which painfully expose both state and federal governments’ failure to address the impact of both structural violence and structural racism on preventable death. The killing of George Floyd by police in Minneapolis has resulted in a national revolt against excessive violence from police, who disproportionately use deadly force on African Americans compared to other groups.1,2,3,4,5,6,7 Risk of death from police use of force generally is unacceptably high in the United States, and for African American men in particular the risk approaches an astounding 1:1000 lifetime risk of death from police, and is a leading cause of death in young African American men.² The United States stands apart from other OECD countries when it comes to police violence, with rates of death from police 5 times higher than Canada and 90 times higher than in the UK, with the likelihood that our current data underestimate these deaths.8,9,10 The excess death from police may stem from inconsistent and lax use-of-force policies with many departmental cultures allowing escalation of conflict, rather than minimization of use of violence. A recent survey of police policies of the 20 largest cities in the U.S. by the University of Chicago Law School found police departments’ use-of-force policies were highly variable, none were compliant with established principles of international human rights law and all of them lacked a basis in state or federal legislation.11,12 Finally, increased police shootings correlate highly with areas of increased homicide rates and are inversely related to restrictive firearm legislation. This suggests, once again, that structural racist policies that increase homicides in African American communities doubly-victimize this population.3,13

Structural violence occurs when social structures harm people by causing the avoidable impairment of fundamental human needs through institutionalized discrimination.¹⁴ These structural barriers contribute to direct violence, such as firearm violence, and increased injury and health burdens in a population. Structural racism is an example of structural violence in the United States where many environmental, legal, and societal arrangements contribute to violence in populations and to maintain racial inequality.¹⁵ The American College of Surgeons (ACS) for years has held the consistent position that firearm violence is a public health crisis and that structural violence is a recognized risk factor for such violence. In concert with 45 medical and injury prevention organizations, including EAST, the ACS stated that a broad, national approach to firearm violence is warranted.16,17,18

The absence of a national firearm policy, a worsening racial wealth gap and violent policing in areas of high homicide rates, inevitably serve to increase firearm deaths in African Americans. Although firearms are only present in less than half of police-involved shootings, deadly force is frequently justified based on the mere possibility of a firearm being present given their pervasive presence in our society.⁷ Historically, major changes in policy of police firearms use, in particular associated with the Garner decision of the US Supreme Court, have led to dramatic reductions in fatalities from police shootings in the 1970 s and 1980 s, without an increase in risk to police—in fact their injury and deaths decreased with more restrictive rules of engagement.19,20,21,22 More recently, the policing experience in Camden New Jersey, including an ethos of “minimizing harm,” has decreased mortality from police shootings by half while violent crime has also decreased.²³ Conversely, evidence exists that police culture that protects out-of-control officers will increase shootings, as officers that show poor self-control are more likely to commit officer-involved shooting.²⁴ Excess police violence then damages the relationship with the community and trust in police such that it significantly inhibits efforts at crime reduction, further aggravating prevention of homicide in these communities.²⁵ Our knowledge of how to prevent deaths from excessive police violence suffer from a chronic lack of systematic reporting of police violence to allow for study of factors that contribute to excessive force, and analyses of existing databases show large heterogeneity between official reporting of police violence and unofficial databases.1,3,6,9,10,13,26,27,28,29 Furthermore, policy changes alone have previously been shown to be inadequate to induce change in police behavior with regards to shootings—broad cultural change with emphasis from leadership on fundamentally changing police behavior has been previously demonstrated to be necessary for change and reduction in mortality from officer involved shootings while novel approaches to community safety are entertained.²¹

In 2016 EAST systematically reviewed the literature on firearm policy and concluded that there is an association between more restrictive laws, such as universal background checks, and lower firearm injury rates. Additionally, it concluded that there are no good data that demonstrate that concealed carry legislation has protective effects.³⁰ Our knowledge of the risk of permissive laws has since been enhanced by recent independent analysis of available evidence by the RAND Corporation. They found that states that have passed “Stand Your Ground” laws experience higher rates of violent crimes and unjustified homicides.³¹ These injuries, as shown by researchers at the University of Pennsylvania examining 462,000 firearm deaths, disproportionately affect African American men, and most firearm legislation to date has shown no beneficial impact on this population.³² Although new evidence that firearm laws like universal background checks have been shown to decrease rates of firearm homicides in African American men by 19%,³³ evidence is mounting that the recent expansion of laws loosening restrictions on possession and use of firearms, such as “shall-issue” conceal permit laws and “Stand Your Ground” laws, may actually serve to worsen homicide rates and contribute to excess mortality in this already vulnerable population.34,35,36,37 Efforts to address firearm homicide through restrictive measures are stymied by the patchwork of state legislation, as the persistent pattern is that firearms are transported across state lines from states with lax legislation and subsequently used in crime.38,39,40,41

Significant evidence is mounting that lax firearm regulation may further worsen racial inequity and increase structural racism: part of a pervasive pattern of inequity experienced by African Americans in health and firearm policy. A 2015 National Task Force on “Stand Your Ground” laws commissioned by the American Bar Association reported that these laws lead to increased racial disparities in the criminal justice system.⁴² This Task Force also reported on uneven application of the law with implicit racial bias in the application of “Stand Your Ground” against African Americans. We already know that violence in African American communities tracks with historical and structurally racist policies such as redlining, which is the systematic denial of various services (like health care or bank loans) by government or private agencies to black people.43,44 Finally, racist attitudes themselves correlate with support for firearm possession and hostility to gun control measures which would likely decrease African American homicide.⁴¹

The oft-stated “protective” justification for ownership and carrying of firearms is outweighed by their use to threaten, maim, and kill, which far exceeds their dubious protective benefit.⁴⁵ Studies have shown for decades that a firearm in the home increases the risk of both homicide and suicide.46,47,48 We know that those who conceal carry a firearm, rather than experiencing a protective benefit, are 4 to 5 times more likely to die of homicide compared to their demographically matched cohorts.⁴⁹ Despite allegations from industry groups of millions of defensive firearm uses each year, this assertion has been widely discredited.50,51,52 Firearms are far more likely to be used to threaten others inside and outside the home.53,54 Far more damning, when evaluated by legal experts, most of the self-reported “defensive use” in surveys were actually unlawful assaults resulting from the escalation of violence.⁵⁵ Indeed, the shooting of Ahmaud Arbery was initially dismissed as defensive until video evidence emerged.

The lack of a national firearm policy acts as a persistent element of structural racism and violence in the United States. Firearms continue to traffic into our cities, resulting in the disproportionate deaths of African American men, whereas concealed carry and “Stand Your Ground” laws combined with more violent policing in areas of higher homicide serve to further aggravate African American mortality. Policies that permit the steady supply of illegal firearms, the routine carrying of firearms, and the escalation of conflict rather than de-escalation create excess preventable homicides and do not reflect a culture that respects life.

Based on the best available data we may conclude:

• 1.More restrictive firearms legislation, such as universal background check laws, will likely decrease firearm homicide, particularly in vulnerable populations such as African American men.
• 2.Violence from police results in an unacceptably high number of preventable deaths, and this disproportionately affects African American men who carry a 1:1000 lifetime risk of death at the hands of police.
• 3.Policies which emphasize de-escalation of violence, and discourage routine carry and possession of firearms will decrease homicide.

In keeping with previous firearm recommendations issued by EAST, the ACS, the American Association for the Surgery of Trauma, and the broad consensus of members of the ACS Committee on Trauma, EAST proposes the following recommendations:18,56,57,58

• 1.We recommend a PICO analysis/generation of a formal injury prevention guideline on restrictive firearm legislation and its potential reduction of African American homicide as a way to address both structural violence and structural racism.
• 2.We recommend a PICO analysis/generation of a formal injury prevention guideline on policies that may decrease trafficking and supply of firearms used in crime, as well as an analysis of existing federal policies that prevent investigation of firearms traffickers and dealers who sell firearms into black markets which then are trafficked for use in firearm homicide.
• 3.We recommend a PICO analysis/generation of a formal injury prevention guideline on police violence as a source of preventable death, exploring fundamental changes to the culture and practice of policing with an emphasis on creation of a national database of police violence, policies and culture of harm reduction and elimination of structurally racist practices.
• 4.We recommend a national commission to investigate the prevalence of implicit racial bias in application of firearms legislation and structural racism as an urgent public health crisis.
• 5.We recommend that all professional societies which support the care of the injured patient should continue to prioritize research and educational resources toward the goal of zero preventable deaths for all, with particular focus on those at greatest risk of violence.
• 6.We recommend the reassessment of all firearm legislation, to include “Stand Your Ground” laws and “shall issue” concealed carry laws, that have been shown to be detrimental to public health.