Firearm Injury Prevention

Gun violence and the prevention of firearm-related injury and death are public health issues of major and growing concern. The American College of Physicians thinks that gun violence and firearm injury prevention must be dealt with as high-priority public health issues as well as criminal justice concerns. The College thinks that physicians must become more active in counseling patients about firearm safety and more involved in community efforts to restrict ownership and sale of handguns. Physicians are directly affected by firearm injuries. In a recent survey of College members, 87.7% reported that they personally had treated or knew someone who had been injured in a gun incident [1]. Internists are very concerned about the preventable injuries, unnecessary loss of life, and consumption of health care resources caused by firearms. This position paper outlines some of the steps that can and should be taken. Definitions Firearms is a generic term encompassing all guns. The Bureau of Alcohol, Tobacco and Firearms estimates that up to 223 000 000 firearms have been produced in or imported into the United States since 1989 and that 192 000 000 firearms are in private hands [2]. It classifies firearms as rifles (70 000 000), shotguns and other long guns (57 000 000), and handguns (65 000 000) [3]. Rifles fire solid bullets, whereas shotguns fire shells containing small pellets. These long guns usually require the user to fire from the shoulder. Handguns can be held in one hand and are of two major types: revolvers and pistols. Revolvers usually hold five or nine cartridges, each in a separate chamber within a revolving cylinder, and must be reloaded manually when the cylinder is empty. Pistols are any handguns that do not contain ammunition in a revolving cylinder. They can be manually operated or semi-automatic. Semi-automatic weapons reload automatically but have a trigger that must be squeezed after each firing. They usually carry ammunition in detachable magazines of various capacities. Reloading can be done quickly by simply replacing the preloaded ammunition clip. Fully automatic weapons reload and fire continuously when the trigger is held and not released. Assault weapons are not precisely defined but are usually considered to be automatic or semi-automatic military-style combat weapons that are capable of rapid fire and use a large magazine. Previous College Positions In fall 1993, the Illinois chapter of the College submitted a resolution to the Board of Governors calling for a ban on the sale and possession of handguns and all assault-type weapons and urging support for other gun control measures. The governors strongly supported the resolution, and the College's Health and Public Policy Committee developed a position paper [4]. The paper outlined some preventive approaches that could be taken and offered recommendations for action. In light of the continuing epidemic of firearm-related violence, the College reaffirms each of the following policy statements. 1. The College supports legislative and regulatory measures that would limit the availability of firearms, with particular emphasis on reducing handgun accessibility. These measures should support restrictions to make handgun ownership more difficult, to reduce the number of handguns in homes, and to eliminate assault weapons. 2. The College urges physicians to inform patients about the dangers of keeping firearms, particularly handguns, in the home and to advise them on ways to reduce risk for injury. If a gun is kept in the home, physicians should counsel their patients about the importance of keeping guns away from children and should recommend voluntary removal of the gun from the home. 3. The College supports the development of coalitions that bring different perspectives together on the issues of firearm morbidity and mortality. These groups, comprising health professionals, injury prevention experts, parents, teachers, police, and others, should build consensus for bringing about social and legislative change. 4. The College supports efforts to improve and modify firearms to make them as safe as possible, including the incorporation of built-in safety devices (such as trigger locks and signals that indicate a gun is loaded). The College also supports efforts to reduce the destructive power of ammunition. 5. The College encourages further research on firearm violence and on intervention and prevention strategies to reduce injuries caused by firearms. New College Positions In light of the recent survey of its membership [1] and the continued need to reduce and prevent firearm injuries, the College adopts the following public policy positions, which include major new proposals and proposals that underscore previous positions. Position 1 Gun violence and prevention of firearm-related injury and death are public health issues that demand high priority for public policy. Rationale: The epidemic of gun violence in the United States has been widely reported [4-11]. The statistics are appalling. From 1968 through 1994, the number of firearm-related deaths increased by more than 60% (from 23 875 to 39 720) [9, 10]. In 1994, 13 593 people were murdered with handguns; 20 540 Americans committed suicide by using firearms, 1610 people were killed accidentally with firearms, and the remainder died from other firearm-related incidents [12]. Since 1991, the annual number of deaths caused by firearms has remained relatively constant. Nevertheless, by the year 2003, gunfire will have surpassed automobile accidents as the leading cause of traumatic death in the United States [13]. In seven states and the District of Columbia, firearm-related deaths already equal or exceed deaths by motor vehicles [10, 14]. The number of deaths from brain trauma as a result of motor vehicle accidents decreased by 25% from 1984 to 1992, largely because of the adoption of preventive safety and marketing measures. Meanwhile, death rates for firearm-related brain trauma increased by 13% [15]. More U.S. teenagers die of gunshot wounds than of all natural causes combined [16]. From 1985 to 1993, homicides involving firearms in the United States increased by 56%; among 15- to 19-year-olds, the rate increased 212%. The firearm homicide rate for white male adolescent victims more than doubled and the rate for black teenager victims more than tripled [16]. Firearms are involved in 65% of suicides among persons under the age of 25 [17]. Suicides among children have been increasing, and the acquisition of guns makes suicide attempts more successful. From 1980 to 1992, the suicide rate for 15- to 19-year-olds increased 28%; for black males in this age group, it increased by 165%; and for all children 10 to 14 years of age, it increased 120%. In Oregon from 1988 to 1993, 78% of suicide attempts with firearms were fatal compared with 0.4% of suicide attempts by drug overdose [18]. For every death involving firearms, twice as many persons with firearm-related injuries need hospitalization and five times as many need outpatient care [19]. About 150 000 persons are treated annually in U.S. hospital emergency units for nonfatal gun-related injuries [7]. The statistics mask the magnitude of the pain and suffering involved and the tremendous amount of human and health care resources consumed by this epidemic. In the movies and on television, gunshot victims usually die instantly or quickly recover. Reality, however, is different. Recovery can be limited and may involve lifelong disability. The financial costs can be staggering-an estimated $1.4 billion to $4.0 billion annually in direct medical costs and $19 billion annually in indirect costs, such as lost future earnings [20, 21]. These costs are reflected in premiums for private health insurance, are often borne by taxpayers through Medicaid, and are often unreimbursed to public and nonprofit hospitals. The preventable loss of life and injury and the resulting pain, suffering, and consumption of human, economic, and health care resources demand that firearm injuries be considered a public health issue requiring immediate attention. The large number of firearm injuries and deaths that occur among children makes it even more compelling to initiate preventive health care measures. Internists overwhelmingly view firearms violence as a growing public health issue that is worsening [1]. Almost 90% of the College membership consider violence prevention to be a priority issue for the College. Position 2 Internists should be involved in firearm injury prevention within the medical field and as part of the larger community. Internists should discuss the dangers of firearm ownership and of having a gun in the home with their patients. Physicians should obtain training on firearms injury prevention, including education about adolescent assault, homicide, and suicide. Physicians should support community efforts to enact legislation restricting the possession and sale of firearms. The College must take an active role in providing education and training for internists on all aspects of violence prevention, including firearm injury prevention. Rationale: Internists believe that the regulation of firearms can reduce gun injuries and deaths and that physicians should support community efforts to restrict ownership and sale of handguns [1]. College members strongly support firearms regulations, such as mandatory registration of all firearms, stricter laws on who should be allowed to buy a handgun, mandatory safety training for gun purchasers, child-proofing of firearms, and a ban on plastic guns that cannot be detected by metal detectors. Internists agree that physicians should be involved in firearms injury prevention, and 84% of College members think it is appropriate for physicians to provide firearm safety counseling to patients [1]. However, less than 20% of practicing internists provide any injury prevention counseling about firearm ownership and storage. Only