Gun Violence – A Public Health Perspective

How do you preserve gun owner rights, but also prevent firearm deaths? It’s a question three UNC researchers are trying to answer.

More than 2,900 Americans die from gun violence each month: 50 are women shot by their partners, 212 are children, and the remaining deaths are attributed to homicides, suicides, and accidentsgraphic by Corina Cudebec
Statistics provided by the Centers for Disease Control.
February 26th, 2018

It’s a survivors’ club no one wants to join. But members keep being added. Concertgoers in Las Vegas. City employees in San Bernardino, California. High school students in Parkland, Florida.

There have been more than 1,600 mass shootings since 2013 in the United States. There is nearly one school shooting a week. Each tragedy rekindles the gun control debate. Is there a solution that preserves gun owners’ rights and prevents further violence?

This is a question UNC researchers are trying to answer. None of these investigators are opposed to firearm ownership. Their research looks at how additional training and effective implementation of existing or new laws can reduce gun deaths.

In some North Carolina counties, a mental health evaluation is required before a concealed carry permit is issued. Adam Goldstein is a clinician and professor in UNC’s Department of Family Medicine. For two years, patients asked him: “Can you certify that I am competent to carry a concealed weapon?” Providing an answer troubles him.

“I try to think of an analogous situation, like assessing whether a person is healthy enough to drive,” Goldstein says. “But it really isn’t the same question. Under what conditions is this person competent to carry a gun? How do I know they know how to use this weapon? What if they develop Parkinson’s disease? It really got me thinking about a physician’s role. As providers, we have little training about guns, and we don’t have a set list of competency criteria.”

Goldstein wondered how a physician fit into this picture. He decided to reach out to his colleagues for answers. He led a team that surveyed 223 psychiatrists, family medicine doctors and primary care providers in North Carolina.  The study, published in the New England Journal of Medicine, surveyed clinicians about signing off on concealed weapons permits.  The majority felt that they could not assess their patients’ physical capability to carry concealed weapons, and a sizable minority did not feel comfortable assessing mental capability to carry concealed weapons.

Goldstein is not the only investigator at UNC exploring the connection between guns and public health. UNC epidemiology doctoral student Josie Caves researches intimate partner violence. Sixty percent of female homicides involve an intimate partner, and 50 percent of those murders are committed using a firearm.

UNC adjunct epidemiology professor Andres Villaveces looks at gun violence from a global perspective. He was a part of a team that explored 130 studies in 10 countries that looked at gun regulations and the subsequent impact on homicides, suicides, and unintentional deaths.

Exploring the findings of these three UNC researchers is important for gaining a clearer picture of the effect of guns on public health.

The physician’s role

Research has shown that access to guns increases the likelihood of suicide — firearms are used in 50 percent of them. A study published in the New England Journal of Medicine compared suicide rates in states with the most and least gun owners. Men in states with the highest rate of gun ownership were nearly four times more likely to commit suicide using a firearm, while women were nearly eight times more likely.

Goldstein’s team published an additional article recently in the American Medical Association’s Journal of Ethics, showing that few physicians reported having conversations with patients about firearms or firearm safety often or very often, and almost half did not ask depressed patients if they had a firearm in their home.  “We uncovered something really simple – we don’t do something we’re uncomfortable with,” Goldstein says. “But while we don’t do something, patients are dying — and that’s a disgrace.”

And his colleagues agree. Eighty percent of the survey’s respondents said that gun violence is a serious public health issue that should be included in medical training. And those providers who completed additional medical education on gun safety were three times more likely to engage in counseling patients on firearm injury prevention.

“This is just a function of training,” Goldstein says. “If we make the training available, providers will feel more comfortable having a discussion about firearms with their patients. And we’re not saying, ‘Don’t have a gun.’ We’re counseling on risk reduction and firearm safety.”

Intimate partner violence
Raluca Iosif worked at IntraHealth International until she was shot and killed by a former boyfriend in Durham in the fall of 2015. Caves is the first recipient of IntraHealth International’s Raluca Iosif Intimate Partner Violence Research Award.

“She lived near my cousin, so it really brought my research home for me,” Caves says. “I am honored to be the first recipient of this award, and I feel tremendous pressure to do meaningful research through this grant in her name and for IntraHealth.”

Sadly, the incident involving Iosif is not a rare occurrence. Every 16 hours, an American woman is shot dead by a current or former partner, according to an Associated Press analysis of FBI and state crime data. Yet, if a partner has a violent past, there are laws in place that aim to reduce gun access. It’s these regulations Caves studies.

The 1996 Lautenberg Amendment prohibits people convicted of assault of their spouse or child from owning or purchasing a gun. It also bans firearm ownership by people under a permanent protective order. But the amendment has a major flaw — people do not always turn over the guns they already own.

“Enforcing existing laws around firearm surrender is very challenging for police,” Caves explains. “That may be why research shows that laws mandating confiscation of firearms typically are not associated with lower rates of intimate partner homicides, while laws restricting an offender’s ability to purchase and possess firearms are.”

That’s why research from the intimate partner violence field suggests that closing the “boyfriend loophole” may be impactful. Currently, an offender has to be married to or have a child with the person they have assaulted in order to lose their access to firearms.

Some states have enacted their own laws to close this gap. A study by researchers at Michigan State University showed a 10 percent lower rate of intimate partner homicide when firearm restrictions that cover all dating partners were enforced.

Four states have taken the Lautenberg Amendment even further, prohibiting firearm possession and purchases by anyone convicted of a violent misdemeanor, regardless of their relationship to the victim. These four states saw a 23 percent lower rate of intimate partner homicides as compared to states without violent misdemeanor legislation.

“Broadening the definition of domestic violence may help,” Caves said. “My research goal is to flesh out the circumstances where regulations can lower rates of violence and where regulations are unnecessary.”

Guns globally

In the 1990s, two Colombian cities implemented a ban on carrying concealed guns during high risk times – from 6 p.m. to 6 a.m. on weekends and holidays – to combat violence. The restrictions led to a 14 percent drop in homicides. The results caught Andres Villaveces’s attention.

“This law had a powerful effect on public health, saving hundreds if not thousands of lives in Colombia,” he says.

Fast-forward to 2016, when Villaveces was part of a team that conducted the first study of how gun laws affect violence around the world. He and his colleagues combed through 130 studies in 10 countries including the United States. They wanted to know if firearm regulations had any effect on homicides, suicides, and unintentional injuries.

“We found different firearm legislative approaches were more effective than others in decreasing mortality,” Villaveces shares. For example, laws requiring background checks reduced the rates of intimate partner homicides. And laws dictating how a firearm should be stored led to lower rates of unintentional deaths in children.

In 1997, Austria not only passed a firearm law that required background checks and safe storage, but also limited access to certain guns like semiautomatic rifles. Firearm homicides dropped by nearly 5 percent and suicides decreased by nearly 10.

Looking toward the future, Villaveces says he would like to study how technology can be harnessed to make gun ownership safer.

“There could be technological changes or solutions we could develop that allow only the gun’s owner to be able to use the firearm,” he explains. “This would be especially helpful for preventing a child who finds a gun from using it.”

Empowering prevention

UNC researchers have found reduced rates of gun violence when firearms are kept out of the hands of children, people who are depressed, and partners who have a history of aggression.

Goldstein is looking forward to rolling out curricula to better prepare physicians to have conversations about gun safety with their patients.

“The quicker we can disseminate this information to clinicians, the quicker we can save lives.”

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Adam Goldstein is a professor and director of departmental advancement in the Department of Family Medicine within the UNC School of Medicine. He is also director of tobacco intervention programs.

Josie Caves is a doctoral student in the Department of Epidemiology within the UNC Gillings School of Global Public Health.

Andres Villaveces is an adjunct assistant professor at the UNC Injury Prevention Research Center.