1. Nelson, Roxanne


Experts say yes, but providers must speak up-and take action.


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The statistics are sobering: nearly 12,000 Americans are victims of gun-related homicide annually, according to the Centers for Disease Control and Prevention (CDC), while more than 78,000 sustain nonfatal firearm injuries. Overall, according to a research letter in the January 3 JAMA, the United States has the highest rate of gun-related mortality among industrialized nations, with more than 30,000 deaths each year due to gun violence. (About a third of gun-related deaths are homicides, others are suicides, and some result from people being unintentionally caught in the crossfire.) While mass shootings often capture public attention, most gun-related violence occurs on a smaller daily scale. "It is really an epidemic-a stain on our nation," says Donna M. Nickitas, PhD, RN, NEA-BC, CNE, FAAN, professor and executive officer of the doctoral program in nursing at the Graduate Center of the City University of New York. "For those of us living in Connecticut, the Sandy Hook incident is ever present."

Figure. A street art... - Click to enlarge in new window A street artist creates a makeshift memorial to the 26 Sandy Hook victims on the six-month anniversary of the 2012 massacre, writing their names and ages in chalk at New York City's Union Square. Photo (C) Reuters / Eduardo Munoz.


Dealing with gun violence in the United States is a thorny issue. The Second Amendment to the Constitution guarantees the right to bear arms, and even discussions about gun violence are met with pushback from those who perceive them as a threat to gun ownership. "Our congressional representatives continue to address it," says Nickitas, "but the problem is that Congress does not have the political will [to take action] because of strong confrontation from the National Rifle Association. It is really a political issue. We are having conversations, but [gun violence] is not at the forefront unless you happen to be a victim, or the family of a victim, or a health care professional on the front lines taking care of the victims," she says.


Although health experts and other advocates have long considered gun violence to be a public health crisis, passing legislative measures to reduce fatalities and obtaining funding to study gun violence continues to be an uphill battle. Research on gun violence has been limited, partly owing to a 1996 congressional appropriations bill stating that "none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control." The bill was introduced after the National Rifle Association campaigned heavily against the agency in response to a 1993 study it funded in the New England Journal of Medicine, which found that keeping a gun in the home was associated with a higher risk of homicide by a family member or close acquaintance. Other government agencies, including the National Institutes of Health (NIH), were subsequently affected by similar legislation, although funding for gun-related research was not banned outright. But while the NIH has been less restrictive about its research funding, the CDC has not funded gun violence research for two decades.


The JAMA research letter also found that from 2004 to 2015, "gun violence research was substantially underfunded and understudied relative to other leading causes of death, based on mortality rates for each cause." Although gun violence killed roughly as many people as sepsis, for example, funding for research on gun violence was only about 0.7% of that for sepsis and the volume of publications only about 4%. Gun violence was not only the least-researched cause of death, it was also the second-least funded after falls.


Last year, the American Medical Association (AMA) issued a statement declaring gun violence "a public health crisis" and called for a comprehensive public health response and solution. The organization outlined a number of measures to be taken; it also resolved to lobby Congress to overturn the legislation that has effectively prohibited the CDC from researching the issue. The AMA statement received accolades but also criticism. An opinion piece on the National Review's blog stated, for example, that "the AMA's declaration is another exercise in science-gilding, which is the covering of one's political beliefs with the veneer of scientific objectivity." In a similar vein, a Forbes opinion column called the AMA's policy statement "a purely political stunt," and added that "a political trade group like the AMA[horizontal ellipsis] cannot invent a 'public health crisis' by simply declaring one."



There are steps health care providers can take to make a difference, despite the current challenges. "We need to highlight the facts and the data," says David E. Stark, MD, MS, coauthor of the JAMA research letter. "I firmly believe in the adage 'you cannot manage what you don't measure,' and all good research, scientific inquiry, or public health intervention begins with admitting ignorance. We have to start off by knowing what we know and what we don't know, then go from there."


Barbara Smith, PhD, RN, FACSM, FAAN, associate dean for research and a professor at the Michigan State University College of Nursing in Lansing, thinks there is public support for taking action to reduce gun violence, but "Congress does not seem to be willing to put forth commonsense legislation." She emphasizes the importance of nurses becoming familiar with their local and state laws. "I do think putting pressure on local legislators may reap some benefit," she says. Additionally, Smith advises that "nurses must educate themselves on what safety measures can help keep guns out of the hands of children, and they can educate families with guns on how to keep the guns and ammunition stored safely when they discuss other high-risk behaviors, such as seat-belt use." However, she notes that some states have attempted to pass legislation to prohibit physicians and nurses from doing just that.


Nickitas reiterates the importance of nurses being informed and educated, especially on issues of mental illness and domestic violence and abuse. "As we prepare undergraduate nurses to enter the workforce, we have to sensitize them to violence in the community," she says. School nurses, for example, can play a vital role in that setting, and help educate children and promote antiviolence efforts at the local level. "We should also expect NPs and public health nurses to have a strong voice, and to take a strong stand, along with our physician colleagues." Nickitas adds that it's also useful to keep elected officials informed and to work with them to find meaningful ways to engage the community.


One problem is that policymakers and the public continue to think that gun violence is strictly a law enforcement issue when it is also a medical and public health issue, explains Charles C. Branas, PhD, chair of the Department of Epidemiology at the Columbia University Mailman School of Public Health in New York City. "Health care providers-beyond simply those in emergency medicine, surgery, and so on, who see cases of gun violence daily-need to speak out much more and realize that they are part of the response to gun violence, the same as police officers, judges, and so on," he says. "Moreover, our large biomedical scientific system in the United States needs to start investing in gun violence as a disease outcome that is worthy of study, treatment, and prevention-the same as cancer, heart attack, malaria, or the Zika virus. The neglect and disproportionate scientific investment are glaring."-Roxanne Nelson