Curbing Gun Violence

HMS internal medicine physician discusses gun reform and health care

AR-15 rifles. Image: Wikimedia

Having undergone her training as a medical student on the South Side of Chicago, Chana Sacks thought she understood the ramifications of gun violence.

Then, in December 2012, during Sacks’ residency at Massachusetts General Hospital, a harrowing personal experience reframed her understanding of gun violence in the most painful of ways. Her cousin’s 7-year-old son, Daniel, was gunned down at Sandy Hook Elementary School in Connecticut. For Sacks, now a Harvard Medical School instructor, gun violence became an aching personal reality. 

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Sacks powerfully captured this scarring—and transformative—experience in a 2015 commentary for The New England Journal of Medicine.

Now, an internal medicine physician at Mass General, Sacks has formed the MGH Gun Violence Prevention Coalition. She co-leads the effort with Peter Masiakos, HMS associate professor of surgery and director of the pediatric trauma service at Mass General, and Paul Currier, HMS assistant professor of medicine and a pulmonary and critical specialist at Mass General, along with Kim Sheppard Smith, a registered nurse.

For this group, the Feb. 14 shooting in Parkland, Florida, that left 17 dead is the latest tragic reminder that their work is more urgently needed than ever.

Sacks sat down with Harvard Medicine News to discuss the state of gun violence research, policy and more.

HMN: Nearly 33,000 people die of firearm injuries in the United States each year and more than 67,000 are injured by gun violence. What does this mean to you as a physician and a scientist?

Sacks: These numbers are staggering and tragic because these deaths and injuries are preventable. While the stats are stark, they actually underestimate the magnitude of the problem, because this is not just about body counts. There were 3,000 students at the school in Parkland and, while thankfully most were not physically injured, those students and faculty and staff and parents and family friends are all facing long-lasting emotional sequelae. It’s important to remember that while mass shootings like this tragedy in Parkland capture the country’s attention, gun violence is a daily reality across the country for many people and many families whose pain never makes the news.

"These numbers are staggering and tragic because these deaths and injuries are preventable." — Chana Sacks 

My colleagues across every discipline—from emergency medicine, trauma surgery, rehabilitation, psychiatry, social work and other specialties—witness the devastation of gun violence firsthand. We all see the devastation of entire families when one person comes in shot.

As a clinician, I thought I understood this issue. I thought I knew what it meant. Then, when Daniel was killed, gun violence became a haunting personal reality.

HMN: Going back to cold clinical numbers, can we put them in a public health context?

Sacks: Thirty-three thousand people die each year from gun violence—that’s the same number of people dying from liver disease, and about the same number of people dying from sepsis. As clinicians, we are taught how to deal with these other causes of death that threaten our patients. I have sat through lectures on those topics, pored over well-conducted research studies funded by the National Institutes of Health. Not a single lecture, no emphasis in the curriculum, hardly any federal research funding for gun violence, which is taking just as many lives. We’re not taught how to approach it.

HMN: If you had a wish list of things to do to curb gun violence, what would the list include?

Sacks: One of the critical things we have to do to address gun violence is to reframe it as the public health and medical issue that it is. Then, we will have the power to approach it in a way that can lead to real solutions. Addressing firearm-related injuries will take a constellation of strategies. Reducing deaths from gun suicides demands a very different approach from one making sure a 5-year-old doesn’t get his hands on a gun and accidentally shoot his sister. We need to develop an understanding of the different pathways that lead to different types of gun violence. We would never expect one treatment to cure every type of heart disease. Whether it’s cardiovascular illness or gun violence, once we understand them we can devise targeted treatments.

At the same time, there are things we already know.  The common link in these tragedies is easy access to firearms. We know that access to firearms is an independent risk factor for suicide and homicide. We know that stronger firearm policies in general and stronger laws regulating permits and background checks are associated with decreased firearm homicides. We know that states with the most firearm legislation have the lowest rates of gun suicide and homicide. We know that in most mass shootings, the shooter gave warning signs that either weren’t recognized or weren’t acted upon. We know that too many guns in this country are not safely stored.

We know from the firsthand accounts of emergency room physicians, trauma surgeons and radiologists who treat gunshot victims that certain semi-automatic rifles spew lethality like no other, causing often irreparable organ damage, the kind once seen only on the battlefield.

We have important, actionable knowledge already, but still, many questions remain unanswered because of the lack of federal research funding. Speaking of a wish list, repealing the federal legislation first passed in 1996 that effectively shut down funding for gun violence research is a first order of business.  When data are absent, people get to choose their own anecdotes and treat them as fact. We cannot develop sound policy from gestalt alone. We have to test interventions and evaluate what works in a measurable way.

HMN: Much has been made of the mental health component in the gun debate. Can you address this?

Sacks: Tackling the mental health aspect of gun violence is, without doubt, critical, but it’s one component in a complex dynamic. There is a risk that people with mental illness get scapegoated in the national conversation. The fact is that people with mental illness are more likely to be victims of crime rather than perpetrators. Painting gun violence as a mental health problem alone is reductive and is exploited by some people who are very good at distracting from the real evidence-based ways of moving forward.

HMN: The human toll of gun violence appears immeasurable. Let’s talk about dollars and cents.

Sacks: The medical costs and loss of productivity alone are estimated to cost tens of billions of dollars a year. When costs of psychological trauma, litigation, the economic impact of lower property values and the closing of businesses in areas of cities that are seen as dangerous are factored in, some estimates reach $100 billion a year or more. The ripple effects spread quickly.

HMN: What is the role of clinicians in informing the public conversation on gun violence?

 Sacks: Our first obligation is to our patients in the clinic, in the hospital, in the emergency room. We must ask about gun safety and firearms in the home. Beyond the walls of the hospital, we have an obligation to speak out about what we witness on a daily basis. We must demand policy change because gun injuries and gun deaths are, at their core, medical. Gun violence affects every discipline in medicine in a really far-reaching way: emergency medicine doctors and nurses, trauma surgeons, primary care doctors dealing with the longer term sequelae, rehabilitation specialists, infectious disease doctors who take care of patients with spinal cord injuries and neurogenic bladder who get recurrent infections, mental health specialists, social workers and so on.

HMN: If gun violence is at its core a public health issue with cultural and political dimensions, how do we disentangle one from the others?

Sacks: I don’t know that they are easily disentangled. But an organized movement demanding substantive change is growing. There are many different groups saying the same thing—enough is enough. The Parkland students are really making a difference, leading with their powerful voices.

Responsible gun owners, of whom there are millions, have a big role to play in this conversation, and many of them are part of the effort for sensible gun reform. This goes to show it’s not “us” versus “them,” although this framing may be politically expedient for some.

But ultimately, we do have to bring the political and cultural discussion back to the core question of how to reduce morbidity and mortality from firearms and how to keep our communities safe. We are talking 33,000 deaths a year from gun violence—what could be more medical than that?