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Thursday Aug 08, 2019

We Must Find Common Ground to Reduce Gun Violence

More than 30 dead. Dozens more injured. Another bloody, deadly weekend in the United States.

[John Cullen, M.D. hunting photo]

Here I am, deer hunting on Kodiak Island with my friend Jim Hurd. That's me on the left.

In the wake of recent shootings in Dayton, Ohio, and El Paso, Texas, six of the nation's largest physician organizations -- including the AAFP -- as well as the American Public Health Association are calling for policies to reduce firearm injuries and deaths and reiterating our commitment to finding solutions to this epidemic.

In my role as president of the AAFP, I have participated in several summits on firearm injuries that have included most of the medical specialties. My experience has been that all of the medical specialties feel the need to address firearm injuries and deaths. One result is an article published Aug. 7 in the Annals of Internal Medicine(annals.org) that highlights the need for research and prevention initiatives. The physician organizations responsible for the article represent 731,000 U.S. physicians.

There are those who will say that physicians should "stay in their lane."(www.npr.org) But like most family physicians, I have a history of treating people affected by gun violence. And like most physicians, my life has been personally affected by the loss of someone I was close to. Having moved from a metropolitan residency training program, where the majority of firearm-related injuries were from gang violence, to my current rural community, where most gun injuries are self-inflicted or accidental, I have experienced a common theme of bullet-induced trauma.

I trained in California during the height of the methamphetamine and crack epidemics. My fellow residents and I became adept at treating gunshot wounds. It was a rare night when we did not care for a victim of violence caused by someone using a firearm. These were young people, often children, who were shot in endless gang violence.

I remember consoling a mother whose daughter lost a hand and an eye to a shotgun injury. The daughter's boyfriend had been the target. And I can't remember all the times I had to tell a parent that they had lost their son or daughter.

During residency, the importance of gun control was clearly evident to me. It seemed the way to reduce gun violence was to remove guns from those who would misuse them.

When I moved to Valdez, Alaska, however, I found that attitudes about gun control were quite different. Guns were everyday tools and a sign of freedom. I had trouble explaining to those in my new community that although they might see gun control as a threat, it was essential to breaking the cycles of violence in many urban communities.

I became a gun owner and hunter myself, with a .338 Browning. For years, most of the meat my family ate was what I could obtain by hunting. I used a large-caliber gun because of the bears who would come running when they heard a shot, as if it were a dinner bell. After returning home, I disassembled my guns and then locked them in a safe separate from the ammunition, recognizing the fascination that children have with firearms. I trained our children in firearm safety, knowing that there were many homes with guns in our community.

Alaska has the second-highest rate of suicide in the country,(www.cdc.gov) and I recently had a patient and member of our community take his life -- and this is far from the first time that has happened. There are many hypotheses about the reasons for this high rate, but it likely has to do with the combination of alcohol, depression and number of households with firearms.

Alaska also has the highest rate of gun ownership in the country,(injuryprevention.bmj.com) at nearly 62%. We live by subsistence hunting, and our children grow up with meat being processed on the kitchen table. They have no illusions about where food comes from.

"I love moose," a 4-year-old once told me.

As in many rural communities, guns here are tools -- just as saws and hammers are. At its best, this culture is an expression of living with the land, respect for animals and taking part in life's cycles.

Unfortunately, rural communities in my state have the highest rate of gun-related accidents and suicides in the country. I respond to several gunshot wounds a year in my community of 4,000, though many never reach the hospital alive. This is the sad testament to the lethality of guns when combined with alcohol, depression and the larger calibers of bear country.

The saddest part is that although 90% of those who attempt suicide and survive never attempt it again, at least 85% of those who try to commit suicide with a gun succeed.(www.apha.org)

As I sit here writing this, the memories of victims of firearm injuries reel through my mind. I have taken care of a child who was killed by his brother at age 5. I have taken care of several patients killed or injured in mishaps with bear-defense guns. I have taken care of women who were shot by their partners. And I have taken care of many men who have killed themselves, usually in conjunction with alcohol. These experiences as a physician give me the right to talk about firearm injures and to actively work to reduce them.

During the American College of Surgeons' Medical Summit on Firearm Injury Prevention earlier this year, I read a great article written by a group of gun-owning trauma surgeons(www.journalacs.org) who were looking for solutions they could live with. They made the point that gun owners would rather hear from other gun owners than from those without firsthand knowledge of gun ownership. There is a cognitive dissonance among gun owners when someone who does not know the vocabulary tries to argue in favor of gun control.

Somehow, we need to come together as a nation on this issue. Treating firearm injuries as a public health issue is an important first step. We did this for motor vehicle accidents and saw a significant decrease in injuries. We did not try to remove cars, we just made them safer. This public health approach worked. Likewise, until we have more data regarding gun-related injuries and deaths, both sides of the debate should work on solutions we can all agree on. Some of these -- including safe storage laws, expanded background checks, research and improved access to mental health services -- are covered in the Annals article.

I think we can all agree that we need to keep children safe from guns. Children have a fascination with guns and bullets. Preventing them from accessing guns by using safes and/or locks is an important step that the majority of gun owners agree with. Programs such as Bulletproof Kids(bulletproofkidsutah.org) arrange for gun locks and safes to be handed out in physician offices, and sophisticated safes with fingerprint scanners allow for quick retrieval of a gun.

I think we also can agree that training in the use of guns is important to make ownership as safe as possible. A 2017 public opinion survey found that roughly 80% of gun owners and nonowners(ajph.aphapublications.org) favor universal background checks and testing requirements for people who wish to obtain a concealed carry permit. Accidental injury is common and affects more than the gun owner. Gun range and hunting safety is as important as the knowledge of how to store guns safely.

The majority of gun owners and nonowners also agree, according to the same survey, that someone likely to commit intimate partner violence should not have access to guns. This individual's friends would hopefully act in the person's best interest to limit that access by holding their guns for a while. We need a culture change so this becomes the norm, or else we need red-flag laws that allow rapid intervention.

Someone who is depressed and suicidal should not have access to guns. Again, we need a culture change where it is acceptable for someone to hand over their guns for safekeeping if they pose a risk.

I think most of us can agree that loopholes in existing gun laws should be closed. For instance, people who are denied access to guns because of previous felony convictions or mental illness or who are a risk to others should not be able to buy guns at gun shows.

There are other issues where agreement will be more difficult. I personally would prefer limits on semiautomatic weapons. I have seen multiple injuries from guns that were thought to be unloaded, and semiautomatic weapons are dangerous to hunt with. I deplore the lack of hunting ethos in hunters who feel they need more than one bullet. What do you call a hunter with a semiautomatic weapon and 15-round magazine? A really bad shot.

There is a reason that semiautomatic firearms are used in mass shootings, as well as in gang violence. They make it easy to shoot a lot of bullets quickly, especially when paired with large-capacity magazines. In the case of the Dayton massacre, the shooter fired at least 41 rounds in a barrage that lasted just 32 seconds.(time.com) Despite the rapid response of police, nine people died and 27 were wounded. Similarly, police engaged the shooter in the recent Gilroy, Calif., attack in less than one minute,(time.com) but the shooter was still able to kill three people and injure 16 others.

In the call to action that our physician organizations have published in Annals, we emphasize the need to improve the health and safety of our patients, their families and our communities while respecting the U.S. Constitution. By focusing on the areas that we can agree on as a nation -- rather than on the areas we don't -- we can significantly reduce the number of people injured or killed by firearms. And because many of these issues (like a bill calling for background checks(www.congress.gov) that passed the House in February) have support from both sides of the debate, there is no reason not to act now.

John Cullen, M.D., is president of the AAFP.

Posted at 09:33AM Aug 08, 2019 by John Cullen, M.D.

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