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Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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3

The Toll on Individuals and Communities

The workshop’s first panel session included two presentations on the toll that firearm violence takes on individuals and communities. Lucas Neff, an assistant professor of pediatric surgery at the Wake Forest University Baptist Medical Center, discussed a case study to illustrate some of the points where a health system could have intervened before the injury occurred. Therese Richmond, the Andrea B. Laporte Professor and associate dean for research and innovation at the University of Pennsylvania School of Nursing and the Penn Injury Science Center, spoke about the psychological and social burdens of firearm violence on communities. A moderated question-and-answer session led by George Isham followed the two presentations.

A PEDIATRIC VICTIM AND OPPORTUNITIES THE HEALTH SYSTEM HAD TO INTERVENE

One of the things that strikes him as a pediatric surgeon, Neff said, is the unprecedented number of pediatric firearm injuries that have occurred over the past 18 months and the fact that he is in the same situation as a pediatric surgeon today as he was when he was a general surgeon in the Air Force, where he had to react to events rather than anticipate and help prevent them. Prevention was not possible in Afghanistan, of course, but Neff said that he and his colleagues felt the same sort of powerlessness in Atlanta where he was completing his pediatric surgery fellowship after leaving the Air Force as he had felt in Afghanistan.

Neff mentioned that C. Everett Koop, the Surgeon General in the Reagan administration, once said that if diseases were killing children at the

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Image
FIGURE 3-1 Leading causes of pediatric deaths in trauma centers in the United States (2010–2016).
NOTES: Firearms accounted for more than 25 percent of all pediatric deaths reported in trauma centers in this period. This presentation used the American College of Surgeons definition of pediatric as aged 0–19. See https://www.facs.org/quality-programs/trauma/tqp/centerprograms/ntdb/docpub for more information (accessed December 27, 2018).
SOURCES: Adapted from a presentation by Lucas Neff at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; ACS, 2019.

same rate as injuries and firearms, the American people would be outraged and demand action.1 Pediatric2 traumas are the leading killer of children in the United States, with firearm violence being the third-leading cause of pediatric deaths (see Figure 3-1). However, when viewed in terms of case fatality rate, firearms are the most lethal (see Figure 3-2). The causes of firearm-related injuries to children include accidental shootings and discharges of weapons that children find unsecured, self-harm among teenagers and young adults, and intentional violence.

Turning to his case study, Neff described Chazmin, a 16-year-old African American girl for whom he cared during his pediatric surgery fellow-

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1 See http://www.cnn.com/TRANSCRIPTS/0105/03/se.01.html for full quote (accessed December 20, 2018).

2 This presentation used the American College of Surgeons definition of pediatric as aged 0–19. For more information, see https://www.facs.org/quality-programs/trauma/tqp/centerprograms/ntdb/docpub (accessed December 27, 2018).

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Image
FIGURE 3-2 Pediatric trauma case fatality rate in trauma centers in the United States (2010–2016).
SOURCES: Adapted from a presentation by Lucas Neff at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; ACS, 2019.

ship and who gave him permission to tell her story at the workshop. At the age of 6 months, her parents were killed by a firearm during a home invasion while she slept in the room next door. From that point, her grandmother raised her in East Atlanta, an area with an above-average crime rate and nightly reports of gunshots. Chazmin also has family members involved in gang activities, but there are no firearms in her home.

Based solely on her age and race, Chazmin has an above-average risk of being injured by a firearm (see Figure 3-3). Her risk was further elevated because of a family history of violence (which was triggering disturbing flashbacks), the neighborhood in which she lives, and mental health issues including behavior problems at home and school and having suicidal ideation. Given those risk factors, Neff said, he wondered where the best opportunities to intervene in Chazmin’s life would have been before she was shot when a vehicle pulled up to the car in which she was riding and emptied 20 rounds into the automobile. Of the five or six people in the car, she was the only one hit—a bullet severed her spine and produced multiple injuries in her abdomen.

Chazmin spent roughly 3 months in the hospital and acute inpatient rehabilitation facility recovering from her injuries, during which time she

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Image
FIGURE 3-3 Pediatric firearm injury data from Atlanta by age and race (2005–2015).
SOURCE: Adapted from a presentation by Lucas Neff at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; ACS, 2019.

had multiple additional encounters with the health care system to deal with various issues related to her injuries. She will be a paraplegic for the rest of her life, and now her grandmother has to carry her to their second floor apartment or else she has to have her grandmother lift her out of her chair and then scoot up the stairs herself.

In talking with Chazmin and her caregivers, Neff said, he found that she did go to annual visits with her pediatrician and that her family had filled out an intake form asking about the availability of firearms in her home. She also had intermittent visits at the local children’s hospital for asthma exacerbations. While those routine checklist items were being done with a fair degree of fidelity, he said, routine screening did not translate into action in the form of violence prevention campaigns in her community.

In closing, Neff acknowledged that prevention is difficult and requires sustained effort. The goal, he said, should be to move from a reactionary model of health care to a more preventive one. “I am hoping we can unlock the needed research and advocacy and move forward,” Neff said, “and in spite of the complexity and the seemingly insurmountable task ahead of us, it is my hope we can draw inspiration from people like Chazmin and from each other and continue to foster a sense of urgency in preventing firearm-related injury in our country.”

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

THE PSYCHOLOGICAL AND SOCIAL BURDEN OF FIREARM VIOLENCE ON COMMUNITIES

Firearm violence is a determinant of the health and well-being of individuals, communities, society as a whole, and health care systems, Richmond told the workshop. Firearm violence is inextricably tied to race and inequity, poverty and poor housing, limited access to healthy food and educational opportunities, and a lack of safe places to work, live, play, walk, and socialize. “All of these factors directly impact health,” she said, “so if we want healthy people in our communities and in our health care systems, we must address firearm violence.”

Richmond said that firearm violence affects everyone and that it is important to get that message across because, as she put it, “if we do not believe it is our problem, we have no incentive to solve the problem. That is true individually and for families, and it is certainly true for health systems.” To illustrate this point, she cited data from a study she and her colleagues did showing that firearm violence is not solely an urban problem (Branas et al., 2004) (see Figure 3-4). The data show that while firearm homicides are more common in urban than rural areas, the reverse

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FIGURE 3-4 Urban and rural shifts in intentional firearm deaths.
SOURCES: As presented by Therese Richmond at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; Branas et al., 2004.
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

is true for suicide by firearm. Multiple regression analysis demonstrated that firearm violence is everybody’s problem when homicide and suicide are combined. Further supporting this idea is a social network analysis that makes the case that almost everybody at some point in their lives has somebody in their social network who is affected by gun violence (Kalesan et al., 2016) (see Table 3-1).

Richmond stressed that it is important from a differential diagnosis perspective to know the burden of firearm violence in one’s own health care system. “If I do not correctly diagnose the problem,” she said, “it does not matter what intervention I am giving, because it is not really going to take care of the problem.”

To drive home this point, she referred to a study that she and her colleagues conducted in the early 2000s (Richmond et al., 2004). This study looked at three small- to medium-sized cities in Iowa, Ohio, and Pennsylvania with trauma centers that served as hubs for treating firearm injuries. The city in Pennsylvania thought of itself as a “gun-toting” community and was not eager to have Richmond and her colleagues looking at the burden of firearm violence there, but it wanted to use those data to secure law enforcement money to address a gun homicide problem that the community blamed on drug traffickers from New York traveling south through the community. However, after gathering data from every source possible—this was before the National Violent Death Reporting System existed—Richmond found that the real burden on the community was not homicide but firearm-related suicide, particularly among older white men (see Table 3-2). In the first meeting with the community, she recalled, the response to this information was largely apathetic. Though she protested that, as a nurse, she could not find this to be acceptable, the community did not feel that firearm-related suicides were a problem that needed solving.

Analyzing the narrative notes, suicide notes, and medical examiner notes, Richmond’s team found that the main reason for suicide was not that these older men were in a terminal state but rather they were afraid of being a burden, were in unremitting pain, had depression, or were socially isolated. Using this information, her team was able to mobilize the community to address these solvable issues.

Richmond then discussed the burden borne by people injured by firearms, which she believes health systems do not adequately address. In a subset of a large cohort study of 623 seriously injured African American men, 55 percent of whom were violently injured, many by firearms (Jiang et al., 2018), it was clear that these men were suffering several psychological problems as a result of having been shot. “The psychological outcomes are profound, and I would posit that as trauma centers and health care systems, we are not dealing with this within our own systems in an optimal way that I believe we can,” Richmond said. The reason to care about that fallout, she

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

TABLE 3-1 Likelihood of Gun Violence in a Person’s Social Network, 2013

Group GV Ratea SN no GV in 1 Yearb (range) SN no GV in a Lifetimec (range) SN GV in a Lifetimed (range)
Overall 37.2×10−5 0.90 (0.90−0.89) 1.5×10−3 (2.4×10−3−0.9×10−3) 99.8% (99.8–99.9%)
Non-Hispanic whites 20.3×10−5 0.94 (0.95−0.94) 29.0×10−3 (37.3×10−3−22.4×10−3) 97.1% (96.3–97.8%)
Blacks 86.6×10−5 0.78 (0.79−0.76) 2.7×10−7 (8.03×10−7−9.04×10−8) 99.9% (99.9–99.9%)
Hispanics 30.2×10−5 0.92 (0.92−0.91) 5.1×10−3 (7.5×10−3−3.5×10−3) 99.5% (99.3–99.6%)
Other race 12.6×10−5 0.96 (0.97−0.96) 11.1×10−2 (13.0×10−2−9.5×10−2) 88.9% (87.0–90.6%)

NOTE: GV = gun violence; SN = social network.

a Proportion of those who are gun violence victims (both fatal and non-fatal) in the specific population.

b Probability of having no one with gun violence in SN is calculated using (1 − rate of fatal and non-fatal gun injuries)291. Range indicates the range of social network size between 270 and 312.

c Probability of no one with gun violence in SN in a lifetime: Kalesan et al. assumed first 60 years to be the time period a person develops his or her personal SN. Kalesan et al. calculated using the formula 100 ∗ ((1 − rate of fatal and non-fatal gun injuries)291)60.

d Having a gun violence victim in SN in a lifetime was calculated using the formula 1 – (100 ∗ ((1 − rate of fatal and non-fatal gun injuries)291)60). SOURCES: Adapted from a presentation by Therese Richmond at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; Kalesan et al., 2016.

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

TABLE 3-2 Firearm-Related Homicides and Suicides per 100,000 Individuals in Three Communities

Homicide Suicide
PA
n = 56
OH
n = 304
IA
n = 45
PA
n = 189
OH
n = 160
IA
n = 280
Death rate per 100,000 2.02 12.50 1.08 6.82 6.58 6.72
Race White 1.36 2.92 0.84 6.96 6.80 6.80
Black 15.9 77.48 10.80 2.64 5.42 3.92
Gender Male 3.26 21.86 1.58 12.24 11.90 13.16
Female 0.70 3.46 0.68 1.46 1.66 1.06
Ratio of firearm deaths to intentional deaths by other means 67% 92% 61% 50% 55% 52%

NOTE: IA = Iowa; OH = Ohio; PA = Pennsylvania.

SOURCES: Adapted from a presentation by Therese Richmond at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; Richmond et al., 2004.

One of the surprise findings from her study, she said, was that the number one reason the men who participated in the study—men who are difficult to recruit and retain—gave for doing so was human connection. “Clearly, there is evidence that we can up our game when we think about the psychological and social burdens of [firearm violence],” Richmond said. One challenge, though, is that psychological responses to trauma often arise after people are discharged and they may not know how to recognize the symptoms and get the help they need. Even when these men knew they needed help, they experienced a number of barriers to getting care, including a fear of judgement, limited access to mental health services, social and cultural barriers, and a belief that professional help would be ineffective (Jacoby et al., 2018b). Richmond said that she believes that breaking down silos is key to addressing this problem. “We are remiss

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

said, is that the victims are likely to experience the symptoms of traumatic stress, use illicit substances, be reinjured by other violent encounters, and become perpetrators of gun violence themselves (Rich and Grey, 2005) (see Figure 3-5). “If we are looking for a point of intervention,” she said, “this population with unmet psychological needs after their first injury are targets for intervention that we should take very seriously.” In short, she said, those injured by firearm violence are more likely to have interactions with the criminal justice system than with the health care system, when their core need is health.

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FIGURE 3-5 Pathways to recurrent trauma among young African American men.
SOURCES: As presented by Therese Richmond at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on October 17, 2018; Rich and Grey, 2005.
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

if we do not address acute psychological responses with the same steely resolve that we address airway, breathing, and circulation. No longer can psychological assessment be viewed as a nice add-on,” she said, referencing a commentary she had written for the Journal of Trauma (Richmond, 2005). “It must be integrated into the very essence of trauma care if we are to improve the outcomes of survivors of serious injury.”

Richmond said that for her, the reasons the health care system needs to address firearm violence are personal. “If you live in a community with pervasive violence and firearm violence, you are likely to have significant health effects because of that,” she said. “The burden is not just when you are physically injured.” There is also an economic burden, for instance (Peek-Asa et al., 2017), as well as a negative effect on the well-being of children. In a survey of children in west and southwest Philadelphia, Richmond and her colleagues found that 95 percent had heard about violence in the community, 87 percent had witnessed it, and 54 percent were victimized themselves (McDonald et al., 2011). Constant vigilance among the youth in these neighborhoods was the predominant strategy for coping with the stress of living in violent communities, she said (Teitelman et al., 2010). Living in a violent community, Richmond said, increases the risk of children and adolescents becoming violent offenders (Nofziger and Kurtz, 2005), experiencing increased depression, suicidal ideation, and suicide attempts (Lambert et al., 2008), and achieving poorer academic performance and having shorter telomere lengths and increased allostatic load (Theall et al., 2017).

In her opinion, Richmond said, health systems have the opportunity to work with communities to change neighborhoods one block at a time, to improve people’s health, and to reduce firearm violence (Tach et al., 2016). Given that the burden that firearm violence lies at the doorstep of the nation’s health care system, taking that opportunity makes sense, she said. Her hospital, for example, has a dedicated trauma resuscitation area to care for gunshot victims. She noted that while the nation is paying attention to mass shootings—and she said that she in no way wanted to minimize the negative effect of mass shootings—the equivalent of mass shootings takes place every day, one shooting at a time. In the same 24 hours of the high school shooting that took 17 lives in Parkland, Florida, in February 2018, her hospital had two trauma alerts and treated six gunshot victims. Richmond also said that because police in Philadelphia often deliver patients with gunshot wounds directly to the emergency department, they are provided entrance into the health care space. While physicians and nurses are focused on treating the patients, law enforcement may concurrently be attempting to question shooting victims. The dynamic of this brings to the forefront the intersection between health care, law enforcement, and race (Jacoby et al., 2018c), requiring health systems to carefully

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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consider the need to develop policies guiding this intersection in order to make patient health and patients’ rights the top priorities.

DISCUSSION

The discussion session began with Lih Young, who did not provide her affiliation, commenting that unless the nation deals with the social determinants of health, there will be no solution to firearm violence. Richmond and Hargarten agreed that this is an important societal issue but also that it is one that may be beyond the scope of health systems to address on their own. Hargarten added that there is now a section in the American College of Emergency Physicians on social emergency medicine that is dedicated to being better at addressing the social determinants that are evident, or perhaps not so evident, when a patient comes into the emergency department. This section is also working with health system leaders on this problem. In his opinion, he said, the biopsychosocial model pulls the health care community together to consider the social determinants as part of a continuum rather than as an add-on concern.

David Grossman from Kaiser Permanente commented that while primary prevention should be a top priority for health systems, so too should secondary prevention aimed at those individuals who have already been injured by a firearm. As an example, he pointed out that the reason patients are asked about recent falls is that it is the best predictor of future falls and, that since it is difficult to do primary prevention around falls, given the lack of good screening tools, health systems focus on secondary prevention. Hargarten replied that there is no question that the effectiveness of secondary prevention is paramount with firearm violence and that health systems need to do a better job at secondary prevention when any form of violence is involved. That said, he added, primary prevention is also critical, given the high fatality rate of suicide by firearm and the lethality of gunshot wounds in general.

Neff said that secondary prevention needs to extend beyond the individual to the entire family, particularly when the patient being discharged was the victim of an accidental firearm discharge in the home. In his experience, he said, the attitudes and perceptions about firearm safety may not change much despite the occurrence of what he referred to as a “seminal event” in the life of the family. He also said that while pediatricians now ask parents about car seats and water temperature in the home, it is almost taboo to ask about firearm access in the home. However, he added, research in Atlanta has shown that people respond well when health systems engage with the community and frame the issue of firearm violence as a disease process.

Richmond said that dealing with the psychological sequelae of violence—as well as of the trauma that people experience throughout their

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

lives—is an important component of secondary prevention that health systems can address now. “We should probably be thinking about infusing trauma-informed care throughout the health system,” she said. While Carnell Cooper from Northeast Methodist Hospital in San Antonio, Texas, said he agreed with Richmond, he noted that there is a nationwide shortage of behavioral health specialists. One way of dealing with the problem that Cooper raised would be by breaking down the silos in health care, he suggested. At Froedtert Hospital’s Level 1 Trauma Center, for example, clinical psychologists are embedded in other practices, including the trauma surgery unit.

A second approach, which Hargarten said his psychiatry colleagues are taking, is to accept that other health care professionals, such as psychiatric nurse practitioners, psychiatric social workers, and clinical psychologists, work with these patients and thus that they should be embedded in the system of care rather than remain siloed in a mental health clinic. “We have got to do a better job of integrating behavioral health services and integration our approach to taking care of patients,” Hargarten said. “We have pharmacists in our emergency department, so why not a clinical psychologist helping us manage these patients with complex behavioral health issues?” There would be financial issues to address, he acknowledged, but if reimbursement is now available for screening in the emergency department for at-risk alcohol use and abuse, it should be feasible to make an economic argument that screening for risk of firearm violence—as well as other approaches to prevention—should be reimbursed as an important service.

Isham asked the panelists if they believe that their health systems do not place as much value on prevention as they should. Richmond said she would not presume to speak for her institution, but she did say that health care systems have a long way to go in terms of breaking down silos and integrating behavioral health. To her, she said, the available data speak loudly to the fact that not meeting behavioral health needs puts people at risk and costs health systems more money in the long term. Neff agreed that this is not a high priority in the health systems he has worked for over his career. “I will say that framing it in the biological terms, as Dr. Hargarten has done, and very much as an epidemiology and public health issue and removing all pretext of politics or large macro-level policy issues from this discussion potentially could go a long way in getting the C-suite [organizational leadership] to buy into it,” he said. One hopeful development, Hargarten said, is the trend for health care systems to partner with public health agencies and to think more broadly about the population health that the Patient Protection and Affordable Care Act (ACA) promoted.

Isham said that despite having a long history as a medical director and chief health officer, he was unaware of the magnitude of firearm injury and death, which, he said, underlines the challenge of raising awareness

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

about this issue across health care professions. His question for Richmond was whether having community-specific data or institution-specific data could raise awareness and prompt action. Yes, Richmond said, saying that was in fact the case with health systems in the three communities she studied and referred to in her presentation.

One thing that Richmond said she has observed is that firearm suicide has such a high case fatality rate that clinicians do not see many victims in the health system and as a result do not realize how important of an issue it can be. She also commented that it is now much easier for health systems and communities to get data because of the National Violent Death Reporting System and other sources of data on deaths. Hargarten commented that he is engaged in a project to get health systems to adopt the Cardiff Violence Prevention Model3 (Florence et al., 2011, 2014) into emergency departments and that he is working with public health and community groups to better understand the patterns of violence that occur in a community. In his experience, he said, it has been fairly easy to get emergency department staff to ask where a person was shot and to enter de-identified data into a system for the community to use. “I think this is a great example of how health care systems can engage meaningfully in the community,” Hargarten said. In fact, he said, the health system where he practices is creating, in partnership with law enforcement, what is essentially an atlas of violence for the community it serves. Such a partnership is proving important, he said, because not all cases are known to the police and the atlas allows law enforcement and public health to be more proactive, not just reactionary, in efforts to address violent injuries in a community setting.

Viviana Goldenberg from Kaiser Permanente asked the panelists about the role that primary care providers can play in screening individuals who have no previous history of diagnosed mental illness—and thus who cannot legally be restricted from access to firearms. Hargarten replied that research is needed to better understand and identify who is at risk of committing firearm-related violence. Such research, he said, should look at individuals starting in childhood because the risk of committing firearm-related violence changes as individuals age, with the risk first becoming apparent at around age 14 and peaking between ages 21 and 24, regardless of where one lives. The National Academies’ Forum on Global Violence Prevention is exploring this issue, he noted. Neff said that health systems should empower their primary care providers to “get in the weeds” with some of these issues of risk identification and should provide these clinicians with the resources and mechanisms to act on a hunch that could save lives.

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3 For an overview of the Cardiff Violence Prevention Model (Cardiff model), see https://www.cdc.gov/violenceprevention/fundedprograms/cardiffmodel/whatis.html (accessed December 27, 2018).

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

Richmond added that work is needed, too, to determine how best to create the conversations that can identify risk, which Isham pointed out has been done with tobacco interventions and pediatric immunizations. Betty Lee Davis, a clinical social worker from the Philadelphia area, suggested that one potential risk factor that could be looked for is a history of exposure to or committing violence, a suggestion that Richmond and Neff supported.

Aerielle Matsangos from the Coalition to Stop Gun Violence asked the panelists if they could recommend how to communicate and work with police officers in emergency situations involving firearms. Hargarten replied that he and his colleagues are piloting a program based on the Cardiff model for collecting data and collaborating with law enforcement and the public to predict and prevent violence, and he said that he sees this as a means of bringing together sectors of civil society to talk about how to make communities healthier and safer. He added that the increasingly common collaborations among law enforcement, emergency medical services, and health care systems to provide better and more immediate care for opioid overdose patients could be an example of a partnering with police to address a public health problem. Richmond agreed with Hargarten regarding the need to “broaden the team” that health systems interact with to prevent gun violence. She noted, though, that work is needed to resolve how to manage interactions among the police, emergency department staff, and gunshot victims in the emergency department.

An unidentified online participant commented that providers are not well-compensated for preventive services, while health departments have prevention in their purview, and asked how health systems can partner with public health to address gun violence. Hargarten once again mentioned the Cardiff model as an example of an effective partnership, adding that provisions in the ACA have prompted public health and health care systems to partner on community assessments. Now, he said, research is needed to develop effective approaches for translating the findings from a community assessment into programs that will affect outcomes at the population level, something health systems have not been good at to this point. Neff noted, however, that language added at the last minute to the Affordable Care Act prohibits public health systems from asking specifically about firearm ownership or enrolling people in firearm safety programs.

Linnea Ashley from Youth ALIVE! in Oakland, California, who is also a steering committee member for the National Network of Hospital-Based Violence Intervention Programs, asked the panelists for ideas to help encourage hospitals and health systems to be open to community expertise that is not necessarily credentialed in the conventional sense but that can connect health systems to people who have been affected by gun violence and also to the community in general. Hargarten said such that expertise can play a critical role in enacting a violence prevention strategy, and again

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×

he referred to the Cardiff model as an example of how the community takes the lead in preventing gun violence, with health care systems providing information to drive community decision making. “Community engagement is so important and has to be genuine in its scope and nature,” Hargarten said.

Anna Cupito from the National Academies asked how the issue of health disparity plays into the discussion of gun violence and if the panelists had any thoughts on how to discuss social determinants of health in a way that includes interventions on gun violence. Richmond replied that since firearm violence is a determinant of health and because social determinants play a role in firearm violence, it is essential to incorporate social determinants of health into any discussion on gun violence. She cited a 2018 study (Jacoby et al., 2018a) that showed that Philadelphia neighborhoods redlined for mortgages in the 1930s are those that sit at the epicenter of firearm violence today. “I think it is inherent on health care systems to look upstream, because our patients live upstream and are affected by those upstream things,” Richmond said. She noted that one of the major emphases of Healthy People 2030 is upstream social determinants as drivers of health.

Hargarten asked if it would be possible for the electronic health record to pop up a social determinant risk assessment or behavioral risk assessment for a patient based on some composite score based on where the person lives and the person’s history and health conditions. Given that there are such algorithms for determining who is at risk of a heart attack or a stroke, Hargarten said he sees no reason that the same things could not be done for the risk of injuries and gun violence. Isham agreed with Hargarten and said that his sense is that the contemporary health system does not collect the kind of information it will need routinely, including on social determinants, to be effective in helping promote the health and good health care of the people that it will serve in the future.

Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 14
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 15
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
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Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 17
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 18
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 19
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 20
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 21
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 22
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 23
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 24
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 25
Suggested Citation:"3 The Toll on Individuals and Communities." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
×
Page 26
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Firearm injuries and death are a serious public health concern in the United States. Firearm-related injuries account for tens of thousands of premature deaths of adults and children each year and significantly increase the burden of injury and disability. Firearm injuries are also costly to the health system, accounting for nearly $3 billion in emergency department and inpatient care each year.

The National Academies of Sciences, Engineering, and Medicine convened a workshop to examine the roles that health systems can play in addressing the epidemic of firearm violence in the United States. This publication summarizes the presentations and discussions from the workshop.

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