The National Physicians Alliance has partnered with the Law Center to Prevent Gun Violence to produce this report, which describes the public health approach to reducing gun violence, including policy recommendations.
Read the full publication below or download Gun Safety & Public Health: Policy Recommendations for a More Secure America.
Gun Violence: A Physician’s Call for Public Health Solutions
Basic Facts about Gun Ownership in the U.S.
The Legal Landscape: The Supreme Court and the Second Amendment
Public Health Solutions
Preventing High-Risk Individuals from Accessing Guns
Doctors, Guns, and Medical Gag Laws
Systematic Blocks to Research, Analysis and Data Collection: Removing Impediments
Restricting Unusually Dangerous Firearms
Design Safety Standards for Firearms
Locking Devices and New Technologies to Reduce Child and Unauthorized Access to Guns
Responsible Gun Ownership: Training and Licensing
Holding Industry Accountable
Regulating Gun Dealerships
The Gun Industry’s Immunity from Lawsuits
Conclusions and Recommendations: The Role of the Medical Professional in the Gun Debate
Appendix A: Sampling of Statements from U.S. Physician Organizations Related to Gun Violence
Appendix B: Annotated Bibliography for Academic Literature on Gun Violence and Public Health
In the late 1990s, while working a shift in a pediatric emergency department, I was called in to see an infant who had been involved in a serious car accident. The car had been totaled. The parents, who were lucky to have survived, were terrified that their baby girl had been riding in the part of the car most damaged in the crash. I braced myself for the worst, and went to examine the child. What I found amazed me. The baby, still nestled snugly in her car seat, greeted me with a smile. I examined her carefully. Not a single bruise. She was completely unharmed. Despite the wreckage around her, she had been spared from injury. Her car seat: her salvation.
When I talk to parents and grandparents who have lost children and grandchildren, spouses and siblings to gun violence, I think about this beautiful baby. The United States has made unbelievable progress in the area of injury prevention. From 2000 to 2009, the Centers for Disease Control report that while the number of vehicle miles traveled on the nation’s roads increased by 8.5%, the death rate related to that travel declined. Sadly, during the same years, we did not see parallel implementation of safety efforts to reduce the number of deaths from gun violence. Instead, due to pressure from National Rifle Association (NRA) leaders and lobbyists, we saw Congress muzzle public health research related to gun violence and its prevention. We saw academic paralysis on one of this country’s major public health crises. The cost of our inaction has been astounding.
As we contemplate the deaths of young children at Sandy Hook, of movie-goers in Aurora, of those at prayer in Oak Creek, of those meeting with their elected officials in Tucson—of the 30,000 annual deaths from gun violence in this country—we need to ask ourselves what it will take to achieve effective public health strategies to end this bloody epidemic. Someday soon, we should hear the stories of parents thankful for the chamber indicators and the safety locks that saved their children, just as the infant I so well remember was saved by her legally mandated car seat. To get to that future, it is critical that physicians have the freedom and determination to educate patients about safe gun storage, about the risks of keeping a gun in the home with young children, and about the importance of considering family members’ mental health before bringing a gun into the home. It is critical that research proceed. And it is critical that physicians share their stories with Congress and other policy makers. Solutions to this grim public health crisis require a view from the front lines of medical care.
Cheryl Bettigole, MD, MPH
President, National Physicians Alliance
2012 – 2013
On December 14, 2012, a young man with serious mental health issues entered Sandy Hook Elementary School in Newtown, Connecticut, with an assault weapon. He shot and killed 26 people, including 20 young children. Americans from all walks of life have struggled to put this horrific event in perspective, another in a string of gruesome mass shootings which steal the headlines but barely reference the core problem: gun violence has reached epidemic proportions in the United States. Each year in the U.S., approximately 30,000 people die from gunshot wounds; more than 60,000 people suffer nonfatal injuries from guns.1 In 2010, firearms were the third-leading cause of injury-related deaths nationwide, trailing only poisoning and motor vehicle accidents.2
Americans own an estimated 310 million firearms—approximately 90 guns for every 100 people.3 Yet research has shown time and time again that the presence of firearms in a home makes its residents less safe. A national study of those who died from accidental shootings showed that victims were more than three times more likely to have had a gun in their home as those in the control group.4 Compared to states with the fewest guns, states with the most guns have, on average, nine times the rate of unintentional firearm deaths.5 The danger of unintentional shootings is especially acute for homes with children. 89% of unintentional shooting deaths of children occur in the home—and most of these deaths occur when children are playing with a loaded gun in their parents’ absence.6
Having firearms in the home also plays a role in an individual’s risk of suicide. One study found that homes in which a suicide had occurred were 4.8 times more likely to contain a firearm than similarly situated neighborhood homes that had not experienced a suicide.7 Average suicide rates are higher in states with higher rates of household firearm ownership.8 That relationship persists even after controlling for differences among states in poverty, urbanization, unemployment, mental illness, and alcohol or drug abuse. States with the highest prevalence of household firearm ownership had suicide rates about 60% higher than states with the lowest level of firearm ownership; that result holds true for men, women, and children.9 Another study found that more than 90% of all suicide attempts with a firearm, if serious enough to require hospital treatment, result in death. Suicide attempts by jumping, by comparison, carry a 34% fatality rate; suicide attempts by drug poisoning carry a 2% fatality rate.10 About 90% of people who have lived through a suicide attempt do not go on to die by suicide.11
The presence of firearms in the home also increases the risk that domestic violence will turn fatal. Women in the United States are murdered by intimate partners or former partners approximately nine times more often than they are murdered by strangers.12 An abusive partner’s access to a firearm increases the risk of homicide eight fold for women in physically abusive relationships.13 Domestic violence incidents involving firearms are twelve times more likely to result in a death compared to non-firearm abuse incidents.14
Given the overwhelming risks and harm to the population associated with firearms, advocates for public health must search for solutions. As described below, an examination of the legal background reveals that, while absolute bans on all kinds of firearms are not an option, there is much that can be done to reduce the risk and frequency of gunshot injuries and deaths.
Opponents of gun legislation frequently cite the Second Amendment to the U.S. Constitution, which states, “A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Courts have universally agreed, however, that the right provided by the Second Amendment is not absolute and that many kinds of gun legislation designed to protect public safety remain valid.
In 2008, the law regarding the meaning of the Second Amendment changed dramatically, when the U.S. Supreme Court held for the first time that the Second Amendment guarantees a law-abiding, responsible individual a right to possess a firearm in the home for self-defense. In District of Columbia v. Heller, the Court struck down Washington, D.C.’s decades-old ban on handgun possession and the requirement that firearms in the home be stored unloaded and disassembled or bound by a locking device (a requirement which had no exception for self-defense).15
The Supreme Court explicitly cautioned, however, that the Second Amendment should not be understood as conferring a “right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose.”16 The Court identified many examples of “presumptively lawful” firearm laws, including laws prohibiting firearm possession by felons and the mentally ill, forbidding firearm possession in sensitive places such as schools and government buildings, and imposing conditions on the commercial sale of firearms.17 The Court noted that this list is not exhaustive, and concluded that the Second Amendment is also consistent with laws banning “dangerous and unusual weapons” not in common use at the time, such as M-16 rifles and other firearms that are most useful in military service.18 In addition, the Court declared that its analysis should not be read to suggest “the invalidity of laws regulating the storage of firearms to prevent accidents.”19
Then in 2010, the Supreme Court held in McDonald v. City of Chicago that the Second Amendment applies to state and local governments in addition to the federal government and invalidated handgun bans in Chicago and Oak Park, Illinois. Again, however, the Court reiterated that a broad spectrum of gun laws remain constitutionally permissible.20
Since the decisions in Heller and McDonald, the courts have been inundated with a flood of lawsuits claiming that the Second Amendment has been violated. These claims have been almost universally rejected, as courts across the country have upheld many types of regulations to reduce gun violence.21 Those who cite the Second Amendment as an obstacle to each and every proposed regulation affecting firearms misrepresent the law on this issue and wrongly stand in the way of laws that are constitutional and, as described below, life-saving.
Preventing High-Risk Individuals from Accessing Guns
Public health researchers have identified certain risk factors that make people more likely to misuse firearms, such as prior violent crimes and the abuse of alcohol. The federal law that prohibits the purchase and possession of firearms by certain individuals does not include all individuals with these risk factors, however. Some states have filled in these gaps, preventing firearm access by people known to be dangerous.
Studies have shown that the following groups are at a significantly higher risk than the general population of committing violent or firearms-related crimes, yet are not prohibited by federal law from purchasing guns:
Those who have been convicted of violent or firearms-related misdemeanors;
Those with a history of abusing alcohol;
Those convicted of juvenile offenses.22
Specifically, a study published in the Journal of the American Medical Association looked at 5,923 authorized purchasers of handguns in California and found that handgun purchasers with at least one prior misdemeanor conviction were more than seven times as likely as those with no prior criminal history to be charged with a new offense after handgun purchase.23
Similarly, numerous studies have associated alcohol abuse with a person’s tendency to engage in violent behavior.24 One randomized trial found that, perhaps not surprisingly, alcohol consumption reduced shooting accuracy and impaired judgment about when it might be appropriate to use a gun.25 Another study found that firearm owners are more likely to drink and drive than those with no firearms at home, and to have more than 60 drinks per month. The same study also showed that heavy alcohol use was more common among firearm owners who also regularly carry the firearm for protection and who keep their firearm unlocked and loaded.26
Research also indicates that individuals convicted of offenses at a young age are very likely to commit further acts of violence as adults. For example, a study analyzing a cohort of low-income, minority youth in Chicago found that those who were arrested before age 18 had a 38% higher likelihood of a subsequent felony conviction by age 26 compared with those who had not been arrested.27
Some, but not all, states have expanded their firearms eligibility criteria:
23 states prohibit gun possession by at least some violent or firearms-related misdemeanants;
20 states prohibit gun possession by at least some alcohol abusers;
27 states prohibit gun possession by at least some juvenile offenders.28
In addition, federal law prohibits people with certain kinds of mental health histories from purchasing or possessing firearms, but this law misses many individuals who have been identified by mental health professionals as dangerous. As a result, several states have broadened the category of mentally ill persons who are prohibited from purchasing or possessing firearms. California law, for example, includes an extensive list of temporarily disqualifying factors relating to mental illness, including: communicating a serious threat of violence against an identifiable individual to a licensed psychotherapist during the last six months, or being held for treatment for mental illness for 72 hours within the last five years.29
Of course, simply prohibiting firearm possession by high-risk individuals is not enough to prevent them from obtaining dangerous weapons if a comprehensive background check requirement is not in place. Because federal law does not require universal background checks, according to the U.S. Department of Justice, “individuals prohibited by law from possessing guns can easily obtain them from private sellers and do so without any federal records of the transactions.”30 One study has observed that the private-party gun market has long been recognized as a leading source of guns used in crimes.”31 As a result, recent discussion aimed at strengthening gun laws has focused on extending the background check requirement to all private sales. While federal bills on this issue have stalled, 17 states have enacted laws that require a background check before at least some private firearm sales. In fact, in 2013 alone, five states, Colorado, Connecticut, Delaware, Illinois, and New York, adopted “universal background check” laws which require a background check for every sale of a gun.32 Such laws have enormous potential for reducing gun deaths and injuries. States with such laws should be the rule, rather than the exception.
Doctors, Guns, and Medical Gag Laws
Medical Gag Laws Nationwide
As described above, studies have repeatedly shown that the presence of firearms in a home makes the residents less safe. Research has also shown that doctors’ advice regarding the proper storage of firearms and ammunition is heeded, and that proper storage can save lives. Yet, federal and state legislators have recently moved to prevent doctors from even talking to their patients about this critical safety issue.
Many gun owners improperly store their firearms, significantly increasing the chances that a child or unauthorized person will obtain it. Approximately one of three handguns is kept loaded and unlocked and most children know where their parents keep their guns.33 In one 2006 study, 73% of children under age 10 reported knowing the location of their parents’ firearms, and 36% admitted they had handled the weapons; 39% of parents who reported that their children did not know the storage location of household guns and 22% of parents who reported that their children had never handled a household gun were contradicted by their children’s reports.34 Many young children, including children as young as three years old, are strong enough to pull the trigger on a firearm.35 More than 75% of guns used by youth in suicide attempts and guns causing unintentional injuries were kept in the home of the victim, a relative, or a friend.36
The proper storage of firearms can reduce these dangers. The U.S. General Accounting Office has estimated that 31% of accidental deaths caused by firearms might be prevented by the addition of two devices: a child-proof safety lock (8%) and a loading indicator (23%).37 Another study found that the practices of keeping firearms locked and unloaded, and of storing ammunition in a locked location separate from firearms have a “protective effect” and may assist in reducing youth suicide and unintentional injury in homes with children and teenagers where guns are stored.38
When they encourage the proper storage of firearms, doctors do make a difference. One study found that 64% of individuals who received verbal firearm storage safety counseling from their doctors improved their gun safety practices.39 Despite this promising statistic, state legislators have moved to make it harder, rather than easier, for doctors to provide this counseling. In 2011, Florida Representative Jason Brodeur introduced a bill sponsored by the National Rifle Association (NRA) that subjected health care practitioners who inquired into gun ownership to disciplinary action. The debate on the bill was based heavily on anecdotal information rather than studies, research or statistics. Nevertheless, the bill was signed by Governor Rick Scott and went into effect on June 2, 2011.40
One month after the bill was signed into law, a challenge was filed in the U.S. District Court for the Southern District of Florida, Miami Division. The challengers were six individual physicians and the Florida chapters of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians.
The District Court granted a permanent injunction against the law finding that it violated the First Amendment’s free speech guarantee and that it limited “the free flow of truthful, non-misleading information within the doctor-patient relationship.”41 The court also rejected the NRA’s argument that the law was necessary to protect Second Amendment rights, stating: “A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient’s right to continue to own, possess, or use firearms.”42 The ruling has been appealed to the Eleventh Circuit Court of Appeals.
At the urging of the NRA, nine other states have introduced physician gag rule legislation in various forms since 2011. Most of these bills have died. Only Montana has enacted similar legislation.43
The gun lobby’s efforts to stifle physicians’ discussion of guns are not limited to state legislation. The Affordable Care Act, otherwise known as Obamacare, which was signed by the President in March 2010, also contains NRA-backed provisions intended to shut down the conversation about guns. Specifically, the law prohibits a wellness and health promotion activity from requiring the disclosure or collection of information about gun ownership. The Act also limits the use of this information by insurance providers.44 However, President Obama’s Executive Actions in response to the Newtown tragedy clarified that requests about firearms and the reporting of threats of violence are not prohibited by federal law (although they cannot be required by certain entities).45
These censorship provisions undermine the independent, evidence-based practice of medicine as well as clinical free speech; gag-laws prevent honest and open communication between patients and health care providers, and they deny patients access to vital clinical data. Doctors must defend their right to speak freely about any subject that affects the health and safety of their patients, as well as for the right of patients to receive this critical information.
Systematic Blocks to Research, Analysis & Data Collection: Removing Impediments
Funding for Gun Violence Compared to Funding for Other Public Health Issues
As with other public health approaches to reducing product-related deaths and injuries, research findings are critical to developing effective, protective interventions and public policy regarding firearms. Only by evaluating the circumstances and aggregating the data on this issue can we expect to make evidence-based decisions to address this public health issue.
Yet, at the behest of the NRA, federal funding for research into gun violence has been significantly restricted. In 1996, Congress approved an amendment to an appropriations bill stripping the Centers for Disease Control (CDC) of its budget for firearm injury research ($2.6 million) and forbidding the CDC from using any funding “to advocate or promote gun control.”46 This language has continued to be included in appropriations bills ever since, and has significantly chilled research on gun violence.
The NRA’s determination to hinder this research arose from a study published in 1993 in the New England Journal of Medicine. The article, authored by Dr. Arthur L. Kellerman and colleagues, was entitled “Gun Ownership as a Risk Factor for Homicide in the Home.” It showed that keeping a gun in the home was strongly and independently associated with an increased risk of homicide. The article concluded that rather than confer protection, guns kept in the home are associated with an increased risk of homicide by a family member or intimate acquaintance.47
The Kellerman article clearly stated that the studies weren’t published as briefs for gun control, but rather to provide data to help people make evidence-based decisions about whether to keep a weapon at home. Since then, the NRA has taken every action in its power to hinder any attempt to study gun violence as a public health problem. The same language stripping all funding used for gun injury research and forbidding “advocacy” was added to the NIH funding bill in 2011.48
In 2004 the National Research Council issued a report, Firearms and Violence, assessing the state of knowledge in the field. The report stated:
…the inadequacy of data on gun ownership and use is among the most critical barriers to a better understanding of gun violence… if policy makers are to have a solid empirical and research base for decisions about firearms and violence, the federal government needs to support a systemic program of data collection and research that specifically addresses this issue.49
Significantly, the NRA’s self-described “point person” Congressman Jay Dickey (R-AR) has completely changed his position from 1996 and recently wrote in favor of funding scientific research into firearm injuries. In a 2012 Washington Post op-ed co-authored by former director of the CDC’s National Center for Injury Control and Prevention Mark Rosenberg, Dickey emphasized his “strong agreement now that scientific research should be conducted into preventing firearm injuries and that ways to prevent firearm deaths can be found without encroaching on the rights of legitimate gun owners.”50
As part of the response to the Newtown tragedy, President Obama issued a Presidential Memorandum directing the CDC and scientific agencies to conduct research into the causes and prevention of gun violence. That Memorandum is based on a legal analysis that concludes that such research is not prohibited by any appropriations language.51 However, the absence of funding continues to impede research.
Where research has been completed, it has indicated that solutions to our nation’s epidemic of gun violence do exist. Gun violence may not be altogether “curable,” but it is treatable. There are policies that can reduce the currently unrelenting toll it has taken on our country. Research can help identify which policies work best.
Restricting Unusually Dangerous Firearms
The features and designs of the available makes and models of firearms vary greatly. While certain firearms are designed with legitimate uses in mind, such as hunting, target practice, and self-defense, other firearms have been equipped with particular features intended solely to increase the number of casualties in a shooting. These features, such as pistol grips, barrel shrouds, and thumbhole stocks, allow a shooter to fire the weapon repeatedly without losing control of the firearm. They have no purpose outside of a combat situation. Firearms with these features are commonly known as assault weapons.
In 1994, Congress enacted a law banning the sale or possession of certain assault weapons and large capacity magazines, the feature that, when attached to a firearm, supplies a firearm with numerous bullets ready to be expelled without reloading. This federal law was allowed to expire in 2004. Nevertheless, seven states (California, Connecticut, Hawaii, Maryland, Massachusetts, New Jersey, and New York) have enacted their own laws restricting the sale or possession of assault weapons, and eight states (California, Colorado, Connecticut, Hawaii, Maryland, Massachusetts, New Jersey and New York) have also restricted the sale or possession of large capacity magazines.52
When assault weapons and large capacity magazines are used in a shooting, more people suffer from injuries and more people die. A review of 56 mass shootings (incidents in which at least four people were murdered with a gun) between January 2009 and January 2013 found that incidents where assault weapons or large capacity ammunition magazines were used resulted in 135% more people shot and 57% more killed, compared to other mass shootings.53 Another study found that after the federal ban expired, there was a 40% increase in homicide rates in areas in Mexico along the Texas, New Mexico and Arizona borders (states that do not ban assault weapons) compared to areas along the California border (where assault weapons are banned).54This finding also supports the conclusion that restrictions on assault weapons and large capacity magazines can reduce the number of injuries and fatalities that result from a shooting.
Design Safety Standards for Firearms
In addition to reducing the casualties in an intentional shooting, laws regulating the design of firearms have the potential to greatly reduce the risk of unintentional injuries. Unlike other consumer products, guns are not generally subject to consumer product safety standards, and gun makers and the NRA oppose such standards, just as car makers opposed seat belts and airbags. As a result, from 2005-2010, almost 3,800 people died and more than 95,000 people were injured in the U.S. from unintentional shootings. More than 42,000 victims of unintentional shootings for this period were under 25 years of age, and more than 1,300 of these children and young adults died.55
As stated in an October 2012 study from the Johns Hopkins Center for Gun Policy and Research: “Although unintentional or accidental shootings account for a small share of firearm related mortality and morbidity, these deaths and injuries are highly preventable through proper design of firearms.”56
For example, on September 13, 2012, a 22-year-old man named Marcus Dixon in Stamford, Connecticut, was joking around with friends when he took out his gun. His friends say he pulled the magazine out of the gun and believed the weapon was unloaded when he put it towards his head and fired. His friends tried to revive him, but he soon died.57
Marcus Dixon didn’t have to die. Many firearms are equipped with a feature known as a “magazine disconnect mechanism” that prevents a firearm from discharging when the magazine is not attached. Other firearms are equipped with a “chamber loading indicator” that indicates whether a gun is loaded. Either one of these devices could have potentially saved the life of Marcus Dixon by either preventing the gun from discharging as it did (with the magazine detached), or clearly indicating that the gun was loaded.
Furthermore, poorly constructed guns can fire even when the trigger hasn’t been pulled, or do not fire when the trigger has been pulled. Guns of this kind are commonly referred to as “junk guns” or “Saturday Night Specials.” These low-quality handguns are often composed of inferior metals or plastic and designed in ways to unreasonably reduce the costs of manufacture. Broadly speaking, these handguns are cheap, easily concealed, and more likely to misfire or malfunction than other firearms.
Unlike its response to other hazardous products, federal law imposes no health or safety requirements on the design of domestically produced firearms. In fact, the federal Consumer Product Safety Act, which imposes health and safety standards on other consumer products from baby cribs to clothing and office chairs to hair dryers, specifically exempts firearms and ammunition from its requirements.58 Furthermore, while federal law prohibits the importation of junk guns through a ban on importation of firearms not suited for “sporting purposes,” this standard does not apply to domestically produced firearms.59 The result is that, except in a handful of states that impose their own standards, firearm manufacturers are not required to consider the safety of the products they make.
In response to the lack of federal design safety standards for domestically produced handguns, seven states have adopted laws addressing this issue: California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, and New York. The laws in California, Massachusetts, and New York are the strongest. These laws require handguns to include certain specific safety features and to undergo certain kinds of “testing” prior to their sale in the state. These design safety tests are intended to ensure the structural integrity of the firearm and to prevent the firearm from misfiring or malfunctioning. Examples of design standards include drop testing (to confirm that a handgun does not fire when dropped) and firing testing (to ensure that a handgun does not malfunction when fired). The strongest state laws require handguns that have these features and have passed these tests to be listed on a roster of handguns approved for sale in the state.
Locking Devices and New Technologies to Reduce Child and Unauthorized Access to Guns
As noted above, gun owners frequently do not store their firearms properly, greatly increasing the risk that young children and other unauthorized individuals will obtain access. This problem is exacerbated by the fact that gun locking devices and gun safes are not held to high standards. New technologies are being developed that may reduce this problem, however.
In October 2005, as part of the Protection of Lawful Commerce in Arms Act, Congress passed and the President signed into law legislation making it unlawful for any licensed importer, manufacturer or dealer to sell or transfer any handgun unless the transferee is provided with a secure gun storage or safety device.60 However, the Act does not apply to transfers by private sellers, and does not require that transferees use the device. Furthermore, even when a gun owner attempts to properly store a handgun, a child or other unauthorized person may still have access to it because not all gun locking devices and gun safes are effective.61 The ineffectiveness of certain gun safety devices has recently caused President Obama to call upon the Consumer Product Safety Commission to evaluate the necessity of standards for such devices. As stated by the President: “We also need to make sure that gun locks and gun safes work as intended. Several gun locks have been subject to recall due to their failure to function properly; that is not acceptable.”62
Eleven states have laws concerning firearm locking devices, although many of these laws go no further than the federal law and only require that such devices accompany the sale of a handgun. California has the most comprehensive standard regarding firearm safety devices. California law requires the Department of Justice to set standards for locking devices and gun safes through administrative rules and requires testing of these devices to ensure conformity with these rules. Locking devices found to meet these standards are listed in a roster of approved devices that may be sold in the state. Maryland and Massachusetts also maintain rosters of approved