Gun Violence as a Healthcare Issue: What Is the Responsibility of Otolaryngologists?

With a greater understanding of the effects of human behavior on health outcomes, healthcare for decades has incorporated prevention strategies into clinical care to reduce the high cost of morbidity and mortality associated with a myriad of behaviors—among them smoking, sun tanning, poor nutrition, and lack of physical activity. Added to this list of preventable behaviors is gun violence, which currently ranks second only to opioid overdose and poisoning as the leading cause of injury deaths in the United States.

Currently, 79% of homicides and 53% of suicides involve a gun. For children, guns are the leading cause of death—over 10,000 people under age 25 were killed by guns in 2020 (Johns Hopkins Center for Gun Violence Solutions. “A Year in Review: 2020 Gun Deaths in the U.S. April 28, 2022. https://publichealth.jhu.edu/sites/default/files/2022-05/2020-gun-deaths-in-the-us-4-28-2022-b.pdf).

Framing the Issue

As with tobacco years ago, framing gun violence as a health issue affecting both individuals and the public can be a hard sell. It took years of research and advocacy to show that the high morbidity and costs of smoking were just too great to prioritize individual rights over public health. The issue for gun violence is complicated with a focus on the Constitutional right to bear arms. In addition, gun violence for many is solely a law enforcement issue that’s dealt with after an injury rather than upstream to prevent it.

Unlike tobacco, however, proving the deleterious effects of gun violence on human health doesn’t take years of research or study; harms are self-evident, and the effects are felt broadly by the victims of gun violence, their families, communities, and the public at large. In terms of cost to the healthcare industry alone, hospital costs to cover care for just the initial gun injury were over $1 billion in 2019, with physician fees adding 20% to the total cost (https://www.gao.gov/products/gao-21-515).

 

Healthcare organizations and others have pushed for years to address gun violence as a public health issue, if not an outright crisis. The American Medical Association declared gun violence a public health issue in 2016, and since then has regularly advocated for safer gun laws and other policy positions. A number of healthcare organizations and executives have recently weighed in, taking a public stance on an issue they believe directly affects them as professionals and citizens. Among the healthcare executives speaking out about gun violence are the CEOs from The Permanente Medical Group, Northwell Health, and a coalition of 10 CEOs from Minnesota Health systems who are collaborating on solutions. Numerous CEOs of companies with over 500 employees are also getting involved. In 2022, these leaders sent a letter to Congress supporting the treatment of gun violence as a public health issue and detailing its detrimental effects on society, including its high cost of $280 billion per year to taxpayers, employers, and communities (https://www.beckershospitalreview.com/hospital-management-administration/the-healthcare-ceos-putting-their-names-on-the-dotted-line-for-gun-safety.html).

Healthcare professionals are also speaking out. As care providers to individuals injured by guns, many see firsthand the immediate and long-term effects of gun-related injuries that can affect people long after the initial injury. “Physicians and all healthcare clinicians who have been dealing with the epidemic of firearms violence in general feel a sense of frustration and anger regarding the mindless and senseless loss of innocent lives,” said Myles Pensak, MD, executive vice president of the Triological Society and professor emeritus of otolaryngology–head and neck surgery at the University of Cincinnati College of Medicine. “As physicians, many of us strongly feel a professional responsibility in addressing this crisis in our country; furthermore, as citizens, we are confronted with issues of politics, ethics, cultural norms, and community values in navigating a profoundly complex and serious dilemma facing all of us,” he said.

Physicians and Advocacy

What does it mean to address gun violence as a healthcare professional? For some, the role could include advocacy to change gun laws; for others, educating individuals and families about gun prevention measures; and for still others, screening individuals at a high risk of gun violence.

Katherine Hoops, MD, MPH, an assistant professor of pediatric critical care medicine at Johns Hopkins University in Baltimore and a core faculty member in the Johns Hopkins Bloomberg School of Public Health’s Center for Gun Violence Solutions, cited a number of evidence-based tools to help clinicians address gun-related violence. (See the sidebar, “Gun Violence Prevention Resources.”) Among them are educational tools such as medical education curricula based on consensus- driven priorities for firearm injury prevention and CME-accredited modules, including clinically relevant firearm policies and extreme risk protective orders. Other efforts are geared toward providing clinicians with tools to screen patients who are at risk of violence or injury, refine counselling algorithms for firearm injury prevention among patients, create easily delivered printed educational materials, and implement community- and hospital-based violence prevention programs.

“From screening for depression and risk of suicide, to providing care for elderly adults with dementia, to counseling on safe firearm storage, to using trauma-informed approaches to care with connection to medical homes and community resources, and even to advocacy for evidence-based policies in their communities, clinicians are poised to make a profound impact on patients’ lives and their risk of firearm violence,” she said.

Some of these measures are geared toward healthcare providers working in critical care and emergency medicine, but specialists such as otolaryngologists also play a critical role in addressing gun violence.

Otolaryngologists and Other Medical Groups Speaking Out

In May 2022, the American Society of Pediatric Otolaryngology (ASPO) sent a letter to its members urging them, regardless of political opinion and affiliation, to advocate for legislative action to prevent and reduce harm resulting from gun violence. As ASPO president, Julie L. Wei, MD, professor and academic chair of otolaryngology–head and neck surgery at the University of Central Florida College of Medicine in Orlando, encouraged members to “model taking action” to create a safer society for children by contacting federal, state, and local representatives to advocate for reasonable gun laws, such as universal background checks, that she said 90% of the country support.

From screening for depression and risk of suicide, to providing care for elderly adults with dementia, to counseling on safe firearm storage, … and even to advocacy for evidence-based policies in their communities, clinicians are poised to make a profound impact on patients’ lives and their risk of firearm violence. —Katherine Hoops, MD, MPH

“I believe pediatric otolaryngologists, along with all physicians who care for children, regardless of surgical or medical specialty, have a role in society to increase awareness, contribute to education, and facilitate or guide patients and families toward necessary holistic care,” said Dr. Wei in an interview, underscoring the broad range of gun-related physical and emotional wounds that can negatively impact a person for a lifetime.

Dr. Wei said that the ASPO’s response to gun violence aligns with that of the American Academy of Pediatrics (AAP), which has advocated for years that gun violence should be seen as a public health issue (http://aap.org/en/advocacy/gun-violence-prevention/). In November, the AAP launched a new coalition advocating for research funding for gun violence prevention.

A partner in that coalition is the American Thoracic Society (ATS). In June 2022, the ATS published a letter urging Congress to swiftly adopt gun laws, among other recommendations (thoracic.org/about/newsroom/atsurges- swift-adoption-of-gun-laws. php). “As healthcare professionals and, more importantly, as citizens, it is long past time to demand that all elected officials, regardless of political affiliation, make a commitment to common- sense and meaningful changes to reduce the impact of gun violence in the United States,” said Stuart Sweet, MD, chair of the ATS Health Policy Committee, in an interview.

Dr. Sweet underscored the reality that ATS members treat gunshot victims in the intensive care unit and see firsthand the violence a bullet can do to the human body. “We know the pain, disfigurement, and death caused by gun violence,” he said. “As healers, it is our job to look for solutions and support the work of people who do have solutions.”

To date, neither the Triological Society nor the American Academy of Otolaryngology–Head and Neck Surgery have issued a policy statement to address gun violence, but Dr. Pensak emphasized that generally the Triological Society is aligned with the American College of Surgeons (ACS). The ACS, he said, is one among numerous physician organizations that support a range of recommendations for reducing firearm violence. On June 2, 2022, the ACS held a news conference to outline important steps needed to accelerate an effective response to reduce violence from firearms (http://youtube.com/watch?v=Rtc7iqce2zY).

Medical and science journal editors are also getting involved. In 2017, editors of journals within the JAMA Network, including JAMA Otolaryngology– Head & Neck Surgery, signed a joint editorial on addressing gun violence as a public health crisis and committing to providing policy makers with timely information to help guide interventions to reduce gun-related injuries and death (http://jamanetwork.com/journals/jama/fullarticle/2657417). More recently, on May 22, 2022, editor-in-chief of the journal Science, H. Holden Thorp, PhD, argued that “scientists should not sit on the sidelines” and urged action to, in effect, push lawmakers to pass legislation for greater gun restrictions (http://science.org/doi/epdf/10.1126/science.add1854). In June 2022, Eric J. Rubin, MD, PhD, editor-in chief of the New England of Journal of Medicine, joined colleagues in saying that physicians play a role in gun violence by becoming “effective agents of prevention” and detailing a number of activities to fulfill this role, such as advocating for funding and infrastructure “to support research aimed at reducing firearm-related injuries and deaths,” as well as to “use our voices to bring data to conversations about policy.” (http://nejm.org/doi/full/10.1056/NEJMp2207552)

As healthcare professionals and, more importantly, as citizens, it is long past time to demand that all elected officials, regardless of political affiliation, make a commitment to common-sense and meaningful changes to reduce the impact of gun violence in the United States. —Stuart Sweet, MD

As editor-in-chief of Triological Society journal The Laryngoscope, Samuel H. Selesnick, MD, focused on the responsibilities of journal editors to accept high-quality studies and ensure that those that pass peer review are passed along to readers. For a journal like The Laryngoscope, this means, he said, welcoming all studies of high quality related to otolaryngology, including studies on trauma that could be related to gun violence. “It is the responsibility of editors-in-chief of otolaryngology journals to seek out and try to publish the highest quality evidence-based medical studies that have to do with gun violence in otolaryngology,” he said.

The healthcare community plays an active role in reducing and preventing a broad range of deleterious health effects related to many different behaviors. Many in this community believe that the same sorts of preventive measures brought to bear on behaviors such as smoking should also be brought to bear on behaviors associated with gun use resulting in injuries and death. People working within the healthcare field can engage in several proactive activities, including advocacy, to substantially add their voices to help solidify gun violence as a public health issue and a healthcare issue, by which action it is hoped that more funding and focus on the issue will improve outcomes.

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Mary Beth Nierengarten is a freelance medical writer based in Minnesota.