A Public Health Approach to Tackling the Role of Culture in Shaping the Gun Violence Epidemic in the United States

Gun-related violence is a leading cause of morbidity and mortality in the United States. In 2016, more than 37 000 firearm-related deaths occurred in the country.¹ Furthermore, 2 or 3 firearm-related injuries occur for every firearm-related death.² The burden gun violence poses for the health of the population is disproportionately larger than it is in many countries. About 35% of global firearm-related suicides occur in the United States and, compared with other high-income countries, firearm-related homicide rates are 25 times higher in the United States.^1,3

Increasing evidence links high rates of gun violence to the ubiquity of guns, high rates of firearm ownership, and low barriers to accessing firearms in the United States.^4-9 Several high-income countries have reduced firearm-related violence through interventions that reduced the availability of guns. For example, after a mass shooting tragedy in 1996, the government of Australia carried out a national reform that restricted ownership of legal firearms, established a firearm registry, and implemented a permit requirement for new purchases, among other measures.^10,11 In 2014, a total of 32 firearm-related killings occurred in Australia, marking a 63% decline from 1990.¹² Similar policies are implemented in Canada, Norway, the United Kingdom, New Zealand, and other countries.¹³

Conversely, the United States does not have a robust federal approach to limit the availability of firearms. Moreover, states vary widely in the laws enacted to regulate the sale of firearms, background checks, and preventing children’s access to firearms. For example, the federal law that requires background checks has several loopholes (eg, allowing gun dealers to sell firearms without a background check if the Federal Bureau of Investigation does not complete the background check in 3 days), and only 6 states require safety training for people interested in purchasing a firearm.⁶ People in the United States own about half of the firearms designated for civilian use in the world, which is, in part, indicative of the broad availability of, and permissive access to, guns.¹⁴

Culture and the Resistance to Tackle Gun Violence in the United States

Given the heavy price the United States pays for its widespread availability of guns and the evidence that limiting availability can reduce firearm-related violence, it seems reasonable to ask: Why is there resistance to limit the availability of guns on a national level?

Federal laws i have not changed drastically to restrict access to firearms despite mounting evidence supporting the importance of gun control and as tragic, highly publicized, incidents involving gun violence continue to befall the United States. Even mass shootings at schools and churches—such as in Sandy Hook, New Jersey, and Charleston, South Carolina—did not create enough momentum to trigger a substantive federal legislative overhaul.

A wide range of factors, including commercial influences, contribute to the current state of affairs and create a set of circumstances that are simply different than that of other high-income countries. Central to these factors, the role culture plays in maintaining the gun status quo in the United States is receiving increasing attention in the sphere of academic public health.^2,15,16 Culture is a complex concept that encompasses many areas. In 1871, anthropologist Edward Taylor defined culture as “that complex whole which includes knowledge, belief, art, law, morals, custom, and any other capabilities and habits acquired by man as a member of society.”^17-19 The meaning of culture is often contested and depends on the discipline, which indicates the need for a multidisciplinary understanding to determine the role of culture in shaping the epidemic of gun violence .

Scholars from several disciplines have explained how complex social (eg, individualism as the defining characteristic of the country), legal (the second amendment, federal structure, and lobbying laws), and historical (eg, slavery and racism) factors have interacted to create a gun culture that favors individual rights over gun control.^20-28 For example, one study found that cultural views, rather than scientific arguments or facts, shape political positions on gun control among people living in the United States.²⁹

Public health scholars have also attempted to quantify gun culture. One analysis found that identifying with a social gun culture was associated with a 2.25 times greater likelihood of gun ownership compared with not identifying with a social gun culture.³⁰ However, public health scholarship has lagged behind in efforts to understand gun culture, which may guide public health action on the gun violence epidemic. This paucity of scholarship concerning gun culture stands in contrast to other health outcomes such as alcohol, in which public health scholarship has focused on the intersection of alcohol policy and drinking culture to formulate recommendations to reduce alcohol-related harm.³¹ The comparatively absent literature in public health on gun culture is understandable. Although culture is indubitably a foundational determinant of health—it shapes where we live, eat, play, and grow—it is difficult to measure the effects of culture on the health of populations and even more difficult to intervene to change a culture that undermines the public’s health.^32-34 What, therefore, might be a reasonable public health approach to tackling gun culture to mitigate the gun violence epidemic in the United States?

A Public Health Approach to Changing Gun Culture

Changing gun culture seems to be a necessary element of tackling the epidemic of gun violence in the United States. Changing gun culture will require creating a new narrative that frames gun violence as a public health issue and highlights the consequences of gun violence on population health. Shifting popular opinion on a prevailing cultural preference has contributed meaningfully to reducing harm in the case of other adverse influences on health. Until the 1960s, up to 75% of driving-related injuries and deaths were attributed to driving while under the influence of alcohol.³⁵ The predominant narrative at the time was that these deaths were largely unavoidable consequences of accidents, and laws against driving under the influence were rarely implemented. Consumer advocacy and grassroots mobilization efforts, which formalized and amplified the voices of victims and their families, rallied resources to mount campaigns for culture change. Advocate groups such as Mothers Against Drunk Driving contributed to legislative efforts for safe road use, often persisting against pushback from lawmakers and the public.^36,37

Another example is the movement to reframe the national conversation on smoking. For years, smoking was viewed as an individual behavior, a habit for millions, and it was romanticized in films and in advertisements. Outcries against smoking in the 1960s and 1970s were opposed by a well-connected and well-financed industry. However, this social movement helped advance antismoking policies by highlighting the adverse health outcomes associated with smoking and the rights of nonsmokers.³⁸ With these examples in mind, we propose 4 avenues that may be useful to public health in its efforts to tackle the gun violence crisis.

First, taking a multidisciplinary approach to the crisis of gun violence can help us identify the appropriate actions needed to push against a deeply entrenched gun culture. Multiple social sciences disciplines, such as sociology and anthropology, have grappled with the meaning and implications of culture for a long time. These disciplines are equipped with the theoretical and methodologic tools to study gun culture and are indispensable partners to public health on this front. Taking a multidisciplinary approach also suggests that tackling gun violence will require addressing the root causes of gun culture, such as racism, which affects almost all aspects of life in the United States. For example, the racial turmoil of the 1960s and 1970s fueled talks of gun control. It was then that special interest groups capitalized on the moment to promote discussions on gun rights as an important element of the national identity. Gun manufacturers used this moment to promote a narrative concerning “the urgent need to protect gun rights” as a means to promote sales.³⁹

Second, public health has little choice but to engage the media to frame the discussion on gun violence as a public health emergency rather than a political debate. This framing can, in part, be accomplished by collaborating with the media to present gun violence research to a broad audience. The democratization of media through digital means provides a potential avenue to cultural change that was unavailable in previous decades. In 2018, emergency medicine physicians mobilized the power of both storytelling and social media (Twitter) by sharing their daily experiences of treating patients suffering from the tragic consequences of gun violence.⁴⁰ The mobilization was organic—like many other efforts by community members working to improve the health of populations. However, it is difficult to change culture by solely relying on such spontaneous efforts.⁴¹ Changing culture will require more deliberate and sustained campaigns to continuously highlight the human cost of gun violence, as was done as part of the larger advocacy efforts to reduce alcohol-involved driving.^42,43

A third approach requires engaging allies with similar goals. Movements such as the March for Our Lives have the potential to push the conversation in the right direction. After a shooting at the Marjory Stoneman Douglas High School in Parkland, Florida, students organized a protest of about 800 000 people in Washington, DC—not counting the other smaller protests in multiple cities—calling for stricter gun control legislation.⁴⁴ Concerted progress will require collaborating with such movements to advance the narrative of gun violence as a public health emergency. Other potential allies can be movements with values that align with the goal of tackling the gun violence epidemic (eg, the Against Suicide Movement) and institutions that shape culture in the United States, such as churches and even movie production companies.

Fourth, although shifts in culture can lead to a change in policy, a policy overhaul can sometimes precede a cultural shift.⁴⁵ For example, shall issue laws in numerous states—which allowed people to walk around with firearms on their bodies—helped further the narrative that firearms are an acceptable everyday cultural object in the United States.²¹ The opposite can be true. At the time of implementing gun-control policies, Australia had a high rate of firearm ownership. Yet, changing the laws was then followed by changes in public views. One factor that helped push gun law reform forward was the commitment of a newly elected Australian prime minister who was willing to use his political capital to create a large coalition of advocates for gun control.¹⁰ The role of key political actors in occasioning inflections in culture holds an important lesson for efforts aimed at changing gun culture in the United States.

Conclusion

The United States has a unique gun culture that is driven by a wide range of legal, historic, and societal factors. Tackling the gun violence epidemic requires taking gun culture into account. Shifting the narrative concerning guns will require engaging other disciplines, harnessing the power of social media and storytelling, collaborating with powerful allies, and urging for gun control legislation that may precede a cultural change.

ORCID iD

Salma M. Abdalla, MBBS, MPH https://orcid.org/0000-0001-5474-4521