The problem of gun violence in the US is deeply complex and especially serious among developed nations in the world. Despite being declared as a major public health issue in 1989 by the American Medical Association Council on Scientific Affairs, gun violence has received remarkably little attention from researchers, due to political controversy and lack of federal funding. Most notably, the 1996 Dicky Amendment prohibited the use of federal funding to the National Center for Injury Prevention and Control for advocating or promoting gun control. Between 2004 to 2015, gun violence research had only less than two percent of the predicted funding and less than five percent of the predicted publication volume, given its mortality rates (1). A review of the current literature on gun policies found that most studies have major methodological weaknesses or inconsistent evidence on the effects of various categories of gun policies on the firearm industry, firearm usage, and firearm fatalities (2). Thus, current discourse on gun violence is severely limited by a weak evidence base and lack of reliable datasets, which prevent the development of evidence-based interventions for gun violence in the U.S.
Gun violence is a serious health problem in the US. Compared to other developed countries, the overall firearm death rate and gun homicide rate are ten and approximately twenty-five times higher in the US, respectively (3). Among young adults, the gun homicide rate is forty-nine times higher in the US, compared to twenty-three other developed countries (3). In particular, gun murder rates for young black men are estimated to be nearly 20 times the national average (16). Although gun violence predominantly affects young black males, the disparity exists throughout the lifespan. Sadly, firearm deaths and injuries in the US are preventable, unjust, and disproportionately affect black populations.
In St. Louis City, an overwhelming proportion of homicides are committed with firearms. Despite accounting for less than half of the population, black Americans bear burden of gun violence. Based on data reported by the St. Louis Metropolitan Police Department, gun violence is concentrated to several neighborhoods in North St. Louis, including Wells-Goodfellow, Walnut Park East, Mark Twain, and Jeff-Vander-Lou (6). These neighborhoods consist largely of black populations with high school education levels and household incomes of less than ten thousand dollars (4,5). Unemployment levels in these neighborhoods are also over four times that of the state or national average (5). Clearly, gun violence is affecting our most disadvantaged communities in St. Louis.
The health impacts of gun violence are long-lasting and pervasive. Other than death, firearm-related injuries are associated with disability, chronic stress, post-traumatic stress disorder (PTSD), injury recidivism, aggression, sleep disturbance, withdrawal, and erosion of social cohesion. Young children, in particular, are more susceptible to the long-term harms of gun violence exposure. Based on the National Survey of Adolescents, higher levels of exposure to violence in children is the strongest predictor of PTSD, and is also associated with more behavioural problems and reduced academic achievement.
Since violence exposure is associated with various negative health impacts, it would be expected that the similar impacts extend to health professionals who are indirectly exposed to violence in caring for victims of gun violence. According to the Medscape Physician Lifestyle Report in 2017, emergency medicine saw the highest and greatest increase in proportion of physicians reporting burnout among the twenty-seven specialties surveyed, compared to survey results in 2013 (18).
“As a medical student in Chicago, I was working with some gun violence prevention programs and eager to try and reduce gun violence within the US. However, throughout my career, I have become more accustomed and use to seeing such incidences within the ER,” said Dr. R (pseudonym), MD, an emergency medicine physician in the St. Louis area (personal communication, July 14, 2018).
Increased exposure to gun violence may lead to emotional desensitization as an adaptation or coping mechanism among health professionals, much like gallows humor. However, more studies are needed to confirm this hypothesis.
Many factors contribute to the complex health problem of gun violence. At the individual level, most factors affect early childhood. Some of the strongest predictors of violent activities in later life are early onset aggressive behavior, aggressive cognitive style, early development of pro-aggression beliefs, and social problem-solving skill deficits (6,9). From a social cognitive standpoint, youths with hostile attributional biases overestimate the degree of hostility in a given situation, have poorer behavioral self-regulation, and believe aggressive responses increase one’s self-esteem or masculinity, thereby leading to more aggression and antisocial behaviours (10).
At the interpersonal level, family and peers are key determinants of violence victimization and perpetration. Family dysfunction, single-parent household, family member criminality, poor parenting practices, poor family bonding, poor emotional attachment, high peer delinquency, and low school connectedness are significant predictors of youth violence (6,9,17). In particular, aggressive or delinquent behaviors in later life is often linked to various forms of violence at home that perpetuate intergenerational transmissions of violence through processes like vicarious learning (9,11,12). Since adolescence is a period of self-identity formation mediated by social relationships, one approach is to target adolescent peer groups and role models. Another approach is through strategic peer affiliation, where pairing with a non-aggressive teammate significantly reduce disruptive behavior in aggressive children without putting non-aggressive children at additional risk (13). Combined with attribution modification programs, family involvement and same-age social skills groups during early child development show promise in reducing gun violence. However, more long-term studies are needed to study the effects of such programs on gun violence in later life.
At the community level, neighborhood deviance and community violence exposure are significant factors of youth violence, although neighborhood deprivation was not significant in a large-scale factor analysis (6,12). Community violence exposure may further be moderated by social mistrust, social capital, severity of violent activity, and chronicity of violence exposure (7,8). However, causal factors of gun violence at the community level are much more challenging to identify, as perpetrators of violence are often also victims and witnesses of violence. Thus, rather than distinct, sequential events in a causal pathway, community violence exposure and individual violent behavior might be better understood as different representations of a common underlying construct: violence involvement. According to this model, violence involvement predisposes youth to violence exposure, aggressive cognitive style, antisocial peer affiliation, and violent behavior – all of which are components of a broader youth social ecology that involves and/or promotes violence (9).
One intervention that targets all three levels is the St. Louis Area Hospital-Based Violence Intervention Program (STL-HVIP), a large-scale prevention program launched in 2018 by the Institute of Public Health at Washington University in St. Louis and funded by a $1.6 million grant from Missouri Foundation for Health. The key premise of STL-HVIP is that violence exposure – specifically, history of violent injury – is the strongest predictor of violent injury. Hospital-based programs like STL-HVIP leverage teachable moments to instigate changes in the individual-, interpersonal-, and community-level factors of gun violence. Teachable moments are emotionally critical events – such as hospitalization from an injury – where individuals assess the causes, significance, and meanings of such events and subsequently become more receptive to positive health behavior change. Through collaborations with two other universities and four hospitals in the St. Louis area, adult and child victims of gun violence are identified at participating hospitals and will work with trained social workers for up to a year after discharge on their education, employment, housing, mental health, and relationship goals. As a result of STL-HVIP, a repository of regional data will also be generated and used for program evaluations and future research. Hospital-based programs like STL-HVIP have been shown to be highly cost-effective at reducing injury recidivism, medical costs, incarceration costs, and lost productivity associated with gun violence (14,15).
However, there needs to be more policy-level interventions to deliver more permanent solutions to gun violence by addressing the macro-level factors that systematically enable gun violence to affect local communities. In particular, policies that reverse the economic and social turmoil created by St. Louis’ white flight and deindustrialization in the latter half of the twentieth century are needed.
Currently, trends in changes to gun laws in Missouri do not appear to be promising. In 2007, the law requiring background checks and licenses for all handgun owners was repealed in Missouri. The repeal was found to be associated with a twenty-three percent increase in gun homicide rates in Missouri between 2008 and 2012, even after controlling for poverty, unemployment, and other potential confounders; meanwhile, national gun homicide rates have declined (19). In 2014, the minimum age to apply for a conceal-and-carry permit in Missouri was also lowered from twenty-one to nineteen.
“Gun violence does not affect the people in power, who could definitely make a difference in the matter,” said Dr. R, “Honestly, if Sandy Hook and the shooting at Parkland did not change the issue, it will be difficult to sway the people in power to do something” (personal communication, July 14, 2018).
In Missouri, lawmakers who voted for the legislative changes that essentially loosened gun laws represent districts that are ninety-three percent white and forty-three percent rural (20). Clearly, there is a need to engage the communities most affected by gun violence in designing gun violence interventions and policies.
Multifaceted problems require multilevel interventions to be effectively addressed. Since many factors of gun violence are deeply rooted in the formal and informal interactions of affected communities, more legislative changes are needed to catalyze change and create more systematic solutions. While the most recent spending bill in March 2018 includes a clarification on the authority of the Centers for Disease Control and Prevention (CDC) to conduct research on causes of gun violence, many researchers remain skeptical on the future of gun violence research, due to lack of funding and restrictive budget language. Ultimately, gun violence is a major public health issue that we cannot solve without first understanding its nature.
Edited by: Sophia Xiao
Photographed by: Dili Chen