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Introduction

Firearm injuries and death are a serious public health problem. In 2020, there were 45,222 firearm-related deaths (CDC, 2022), and each year there is estimated to be more than 80,000 visits to U.S. emergency departments (ED) for nonfatal gunshot injuries (Kaufman et al., 2021). In 2017, firearm injuries became the most common cause of injury-related death (Lee et al., 2022), and in 2020, firearm-related injuries became the leading cause of death in children and adolescents (Goldstick et al., 2022). Firearms are used in more than half of all deaths by suicide (CDC, 2022; Conner et al., 2019). Approximately 40 percent of individuals admitted to the emergency department for gunshot wounds experience relatively minor physical injuries and are treated and released from the emergency department, but the other 60 percent of nonfatal gun injury patients admitted to emergency departments face more severe gunshot injuries and are hospitalized (Kalesan et al., 2018). According to estimates from the U.S. Government Accountability Office, hospital costs for initial gun injury care total more than $1 billion a year, with costs associated with physicians’ fees adding some 20 percent to that total and postdischarge care costing hundreds of millions of dollars more each year (GAO, 2021).

In 2013, following the Sandy Hook tragedy, President Obama directed the Centers for Disease Control and Prevention (CDC) to mount a research initiative, and CDC in turn requested the Institute of Medicine (IOM), now

the Health and Medicine Division,¹ and the National Research Council to conduct a study. The resulting report, Priorities for Research to Reduce the Threat of Firearm-Related Violence (IOM and NRC, 2013), laid out priorities for a 3- to 5-year research effort. In 2019, the Board on Population Health and Public Health Practice of the National Academies of Sciences, Engineering, and Medicine convened a workshop that examined the roles that health systems can play in addressing the epidemic of firearm violence in the United States. The resulting proceedings, Health Systems Interventions to Prevent Firearm Injuries and Death, highlighted effective interventions that health systems can implement to address firearm injury and death (NASEM, 2019).

STATEMENT OF TASK

To continue the discussions from the 2019 workshop, Northwell Health and the PEACE Initiative requested that the Board on Population Health and Public Health Practice convene a workshop to gather ideas on how to integrate firearm injury prevention into the entire health care enterprise. The board convened an ad hoc committee and charged it with the following statement of task:²

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¹ As of March 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine continues the consensus studies and convening activities previously carried out by the IOM. The IOM name is used to refer to publications issued prior to July 2015.

² The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

• How to adapt and implement public health and harm-reduction strategies across a variety of health care settings (emergency departments, surgery, primary care settings)
• The need for diverse perspectives in shaping health care firearm injury harm-reduction strategies:
  • Patient/survivors
  • Owners of firearms
  • Community-based voices (community-based organizations)
• Key elements of a health care industry road map for overcoming barriers to integrating harm-reduction and public health strategies around firearm injury prevention into routine care

OPENING REMARKS

The workshop began with opening remarks from the president of the National Academy of Medicine and representatives from Northwell Health and The PEACE Initiative, the two organizations sponsoring the workshop.

National Academy of Medicine

In his introductory remarks to the resulting workshop, Victor Dzau, president of the National Academy of Medicine, called firearm deaths and injury one of the most pressing health challenges facing the nation. From 2006 to 2014, the initial cost of inpatient hospitalization exceeded $6 billion or more than $700 million per year, a figure that Dzau said was likely much larger today (Spitzer et al., 2017). Prior to the start of the COVID-19 pandemic, firearms were one of the five leading causes of death for Americans under age 65, but firearm violence in the United States surged to record levels during the pandemic, increasing by greater than 30 percent. He noted, too, that firearm deaths and injury disproportionately affect certain populations, including those in urban areas, as well as Black, American Indian, Alaska Native, and Latino/a communities.

“There is an urgency to address this topic, and with an issue as complex as firearm violence, it takes a village to move the needle,” said Dzau. “We need to address the whole spectrum of prevention and intervention with the full range of stakeholders.” The health care system, and hospitals in particular, have an important role to play given that they see the consequences of firearm violence every day and because they can be strong partners in promoting community health, he said.

Since the release of the 2019 National Academies proceedings, the CDC and National Institutes of Health (NIH) have made efforts to restart research on firearm injuries as a first step toward preventing firearm-related violence

and injuries. In addition, said Dzau, many other organizations, including the workshop sponsors Northwell Health and the PEACE Initiative, have continued to advance important efforts to address this issue. For example, Northwell Health launched the Center for Gun Violence Prevention, while the PEACE Initiative continues to support other organizations in their efforts to prevent firearm violence.

Dzau noted that this workshop will serve as an update to the 2019 workshop but with a distinct focus on addressing the barriers that health systems face to incorporate firearm violence prevention strategies into routine care and enabling the facilitators that can help them overcome those barriers. In addition, this workshop would focus on how health systems might incorporate input from important stakeholders, including members of communities affected by firearm violence, when considering how to overcome such barriers and enable facilitators.

Northwell Health

Michael Dowling, president and CEO of Northwell Health,³ explained that his extensive involvement in the issue of firearm death and injury prevention began after the 2019 mass shootings in El Paso, Texas, and Dayton, Ohio. “As the leader of the largest health system in New York and the largest employer in New York, I felt that it was our responsibility—and the responsibility of all hospitals and health systems—to get involved in addressing what is clearly a public health issue,” said Dowling. “Many people argued back then that we should ‘stay in our lane,’ that gun violence is not something that we should be involved in, but I argue the very opposite. We have an obligation to be involved and try to make a difference.”

Northwell’s response was to establish the Center for Gun Violence Prevention to organize Northwell’s advocacy initiatives and help the health system focus on influencing public policy, public opinion, and elected officials, as well as educating the public about the extent of firearm death and injury.⁴ Northwell has also held three national forums on gun violence and established a learning collaborative that now includes more than 500 health care professionals from organizations nationwide who are working together to make firearm death and injury prevention a priority. “If you are in the health care field and you are interested in health and public health, then you have to be interested in what to do about gun violence,” said Dowling.

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³ Complete affiliation and titles for all speakers and moderators are available in the biographical sketches found in Appendix D.

⁴ Additional information is available at https://www.northwell.edu/center-for-gun-violence-prevention (accessed August 10, 2022).

With a grant from NIH, Northwell in November 2021 began screening patients who went into its emergency departments to assess who might be a potential victim of gun violence. So far, the health system has screened thousands of individuals at three of its hospitals (Long Island Jewish Medical Center, Cohen Children’s Medical Center, and Staten Island University Hospital), with plans to expand the screening to other hospitals. Dowling encouraged other health care organizations to not only do the same, but also learn more and implement violence intervention programs within the communities they serve. In concluding his remarks, Dowling said:

Jose Prince, vice chair of surgery at Northwell Health and surgeon-in-chief at Cohen Children’s Medical Center, added a sobering reminder to the workshop. Several weeks prior to the workshop, a gunman shot 10 people aboard a Manhattan-bound N train as it pulled into the 36th Street station in Sunset Park, Brooklyn. Five riders were critically wounded, and more were injured in the following chaos. While that event made the national news, a little over a week before, in a less-publicized event, the ex-boyfriend of a Northwell Health employee shot her nine times in a parking garage as she left work, killing her. “Each of us can think about the impact of gun violence in our own neighborhood,” said Prince.

The PEACE Initiative⁵

On the morning of October 27, 2018, a sole perpetrator carrying an AK-47 assault rifle launched an antisemitic attack on the Tree of Life synagogue in the Squirrel Hill neighborhood of Pittsburgh, killing 11 people and injuring 7, including first responders. Within 30 days of the deadliest attack in history on this religious minority community in the United States, more than 40 entrepreneurs from Pittsburgh, plus several honorary Pittsburghers including Bernard Rosof, cochair of Project M.D. of PEACE Initiative, gathered to discuss how to best respond to this attack. The answer, said Rosof, was to

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⁵ Additional information is available at https://www.peaceinitiative.org/ (accessed August 10, 2022).

work collaboratively with established community partners to help imagine, enable, facilitate, and fund fresh initiatives driven from an entrepreneurial perspective. The idea, Rosof explained, was to consider how the PEACE Initiative, a network of community leaders focused on addressing how health care relates to firearm violence in America, could identify key initiatives and help those community partners collaborate across their silos to move much more nimbly, measure results, drive actionable pilots, and then promulgate and use what works.

Convening this workshop, which is focused on how the health care community could come together to bring a perspective to firearm injury prevention that is driven by health care, was one of those key initiatives. Rosof said:

The PEACE Initiative is a small organization with big dreams, said Rosof, with the energy to support this effort driven by the haunting memory of what firearms can do to devastate communities. In closing, Rosof said:

ORGANIZATION OF THE WORKSHOP

An independent planning committee organized the 1-day virtual workshop in accordance with National Academies procedures. The planning committee members were Andre Campbell, Erica Ford, Kayla A. Hicks, Kyleanne Hunter, Sandeep Kapoor, Peter Masiakos, Megan Ranney, Joseph Sakran, and Chethan Sathya. The workshop was broadcast live over the web, and workshop presentations were subsequently posted to the web along with links to the videos of the talks.⁶

This publication summarizes the workshop’s presentations and discussions that occurred throughout the workshop’s four panel discussions; Panel 1

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⁶ Available at https://www.nationalacademies.org/event/04-25-2022/facilitating-the-integration-of-firearm-injury-prevention-into-healthcare-a-workshop (accessed August 10, 2022).

discussed health care strategies to reduce firearm injury and mortality; Panel 2 presented barriers and facilitators to implementing hospital-based firearm injury prevention strategies in urban and rural communities; Panel 3 discussed collaborating with communities to improve health care system implementation success and destigmatize gun violence prevention; and Panel 4 explored a firearms violence prevention road map for hospitals and health systems. In accordance with policies of the National Academies, the workshop did not attempt to establish any conclusions or recommendations about needs and future directions, focusing instead on issues identified by individual speakers and workshop participants. Appendix A contains the references, Appendix B contains the workshop agenda, Appendix C contains the workshop statement of task, and Appendix D provides biographical sketches of the workshop speakers and moderators.

The workshop summary was drafted by rapporteur Joe Alper in collaboration with National Academies staff members Rose Marie Martinez and Dara Rosenberg as a factual summary of what occurred at the workshop, and the National Academies does not endorse or verify the statements.

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