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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

World Report

224 www.thelancet.com Vol 388 July 16, 2016

The long road to gun control in America State-level action on gun control has been steadily increasing since 2012, but the absence of a strong federal response still hampers real progress in the USA. Sharmila Devi reports.

Racial tension is set to embroil the USA this summer after two black men were shot dead by police in separate incidents fol- lowed by the killing of fi ve police offi cers during a demonstration against police violence in Dallas, TX, on June 8. In response to these latest acts of gun violence, President Barack Obama said easy access to guns nationwide had exacerbated divisions between police and citizens. “We also know that when people are armed with powerful weapons, unfortunately it makes attacks like these more deadly and more tragic, and in the days ahead we’re going to have to consider those realities as well”, Obama said.

These recent killings follow the deadliest mass shooting in US history, in which a gunman pledging allegiance to ISIS shot dead 49 people at a nightclub in Orlando, FL, on June 12. Since the Orlando massacre, Democrats in Congress have promised to pressure Republicans to push through gun control reform. They staged a sit-in protest lasting almost 26 hours in the House of Representatives on June 23, but to no

avail. Federal eff orts have also failed in previous years despite rising anger at other mass shootings, such as the killing of 20 children and six adults at the Sandy Hook Elementary School in Newtown, CT, in 2012.

Some signs of progress The latest push might be revived in Congress this month. But even if it fails, activists point to measures being passed by a growing number of states across the country. Gun control has also emerged as a key issue in the presidential bid of Hillary Clinton after previous Democratic candidates, including Barack Obama, steered clear during their campaigns. “We’ve never had a sit-in before and gun control is going to play a big part in November’s [presidential elections]”, Mary Wooley, head of Research!America, which campaigns for greater medical research, told The Lancet.

Along with the political progress at the state level, public health experts are heartened by a growing recognition of the importance of research into gun violence. But they say such research will not fi ll the gap left by the Centers for Disease Control and Prevention (CDC), the leading federal public health agency. Although it compiles data on gun injuries and deaths, it has not funded any major studies aimed at reducing harm from guns after Congress barred it in 1997 from any research that will “advocate or promote gun control” under pressure from the powerful pro-gun lobby the National Rifl e Association.

More than half of Americans (58%) support research into the causes and prevention of gun violence, according to a poll commissioned by Research!America and carried out before the Orlando shootings. “I think that number would be higher if people were asked today”, Wooley said.

Other polls have shown that many Americans who support the right to bear arms also support restrictions such as background checks, assault weapon bans, and a federal database to track guns. Meanwhile, some activists say speaking about gun “safety” rather than “control” helps to persuade more Americans of the need for new laws.

Nine states have added or expanded background checks on their own, according to the Law Center to Prevent Gun Violence. 20 states have strengthened gun laws related to domestic violence and at least 19 states, including Florida and Massachusetts, have passed laws aimed at improving databases used in background checks. “Since Sandy Hook in 2012, there have been 138 new gun laws in 42 states. This is unprecedented momentum at the state level”, Allison Anderman, staff attorney at the law centre, told The Lancet. “Support for background checks has had support of around 90% for many years. The question is when this will become a voting issue and when will the public vote out a legislator who votes against universal background checks even though a majority support it.”

Federal law requires licensed gun dealers to do background checks but not other individuals who are selling a gun. Several states, such as Maine and Nevada, will hold ballot initiatives on this in November, she said. The battle at the state level has been likened to the push for marriage equality for same-sex couples that first gained

“‘Since Sandy Hook in 2012, there have been 138 new gun laws in 42 states. This is unprecedented momentum at the state level’…”

Memorial service for the victims of the Orlando mass shooting, June 19, 2016

World Report

www.thelancet.com Vol 388 July 16, 2016 225

traction with state victories. “It is a fair comparison but preventing gun violence requires many hundreds of diff erent laws”, said Anderman.

Gun violence has been described as a “complex biopsychosocial disease”. Of the 90 deaths a day in the USA caused by gun violence, some two-thirds are suicides. “Everyday violence doesn’t make the headlines. As much as events such as Orlando elevate the epidemic of gun violence to the broader public, the process of social and legislative change is incremental”, Ted Alcorn, research director for Everytown for Gun Safety, a grassroots organisation seeking to end gun violence, told The Lancet.

Federal research needed Everytown for Gun Safety has tried to remedy the dearth of research by doing studies into the causes of gun violence and developing evidence- based policies in the courts, Alcorn said. ”But the CDC has the biggest collection of experts in the world and it should play a critical role.”

The bar on funds being used to “advocate or promote gun control” was extended to other agencies including the National Institutes of Health in 2012, said Courtney Lenard, a CDC spokesperson. “The CDC curtailed its previous research on gun violence not because it was legally prohibited but rather because in 1997, Congress cut the CDC’s budget by an amount equal to what had been spent on research into gun violence”, she told The Lancet. “CDC’s Injury Centre has very limited discretionary funding to dedicate to fi rearm violence research and prevention. In order to pursue research into the causes and prevention of gun violence, the $10 million funding requested in the [fiscal year 2017] president’s budget would be necessary.”

At its annual meeting in June, the American Medical Association (AMA) called gun violence a “public health crisis requiring a comprehensive public health response and solution”. Additionally, the AMA resolved to lobby Congress to overturn legislation that for

20 years has prohibited the CDC from researching gun violence.

Daniel Webster, director of the Johns Hopkins Centre for Gun Policy and Research, is one of a handful of academics in the USA who does research into the causes of violence. “There are maybe ten to 12 of us working in the field, no more than 20”, he told The Lancet. He believes the CDC “if it wanted could use its existing appropriations to study youth and domestic violence and to examine the role of guns in these murders. There are federal funds but by and large, federal agencies are very careful about what they fund to avoid budget cuts.”

He also advocated other steps to fi ll in the knowledge gap such as boosting the Federal Bureau of Investigation’s Uniform Crime Reporting Program. At present, police departments submit data on a voluntary basis and there is no standardised method of including non-fatal woundings involving firearms, he said. “While it records diff erent types and numbers of crimes, we don’t know when someone is shot unless they die. We don’t know how many assaults might have involved a gun to threaten someone or if ten bullets were fired and the person survived”, he said.

California’s state legislature voted on June 16 to establish the California Firearm Violence Research Center at the University of California with US$5 million in funds, helping to fi ll “the gap left by Congressional restrictions on fi rearms research”, said a press release from Lois Wolk, the California senator who pushed for it. “We know that using real data and scientifi c methods, our best researchers can help policy makers get past the

politics and fi nd real answers to this public health crisis to help save lives in California and throughout the country”, she said.

Although the new centre was a substantial boost to research, it would not replace the CDC’s “brand” and capabilities, said Julio Marcial, programme director of the California Wellness Foundation, which has given $940 million in grants for health promotion, wellness education, and disease prevention. Since 1993, some $135 million of this money was related to violence prevention as California led the nation in the number of young people killed in gun violence. Since then, the state’s youth homicide rate has been reduced by more than half and it now has one of the lowest firearm death rates in the country after passing some of the toughest gun control measures. But the gun murder rate across the country has also fallen by about 49% since 1993. More research could try to see what connection if any this drop had with any gun control measures. Marcial said: “There are many causes and many solutions and what works in one area may not work in another. We are in the marketplace of ideas for what works.”

One project he pointed to was the National Network of Hospital-based Violence Intervention Programs. Network members including trauma surgeons and other front-line health workers engage patients when they are recovering after a violent injury to reduce the chances of retaliation and recurrence. Case managers might make home visits, organise cognitive behavioural therapy, and help patients to get better access to government services. “The philosophy of these programmes is that violence is preventable and that trauma centres and emergency rooms offer a unique opportunity at the hospital bedside… to most eff ectively engage a victim of violence and stop the cycle of violence”, says the network’s handbook for starting up a new hospital-based programme.

Sharmila Devi

“‘The CDC curtailed its previous research on gun violence not because it was legally prohibited but rather because in 1997, Congress cut the CDC’s budget…’”

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