Opinion-Editorial

Guns, Politics, and the Emergency Department

What is our role as physicians in confronting the intersection of politics and health?

After the November 2018 workplace shooting and killing of one of our emergency physician colleagues,1 a Facebook group called EMDocs exploded in controversy over a discussion regarding gun violence. Some argued that it is not our place to inject politics into such a forum, which caused a large number of members to leave the group. It has additionally sparked much debate and conversation among our community. This discussion occurred during a campaign by many physicians using the Twitter hashtags #ThisIsMyLane and #ThisIsOurLane in response to the National Rifle Association (NRA) telling doctors to “stay in your lane”2 instead of adding our voices to the gun debate.

There are a few sides to this debate in the EM community. One side seeks to look at gun violence from an academic perspective, advocating for the federal government to fund research on firearm injuries before staking a position in the debate. Another side argues that we already know guns kill and maim (anecdotal evidence and from other countries) and that the only way to prevent these deaths and injuries is by restricting access to guns. Yet another group believes people - not guns - commit violence and the only possible solution is to address the human factor. (Full disclosure, I fall into Camp 2. I believe the most effective way to address our high rate of gun-related injuries and deaths, among our peer nations, is to better limit access to firearms.3)

I’ll never forget my first patient during residency who died after being shot. I’ll always remember the look of horror that was frozen on his face. I can’t forget seeing the scene of his shooting on TV, thinking to myself that this is something no one should have to go through in life or in death, not something any family or community should have to deal with.

No short piece seems capable of shifting opinions on this topic, however evidenced-based it is, but I think the more important conversation that has been sparked, and that is inherent to the “#ThisIsOurLane” movement, is just what is our role as physicians in confronting the intersection of politics and health. We must be willing to engage in honest dialogue and consider politics as a part of medicine.

Certainly, the beginning of medicine focused on individuals and their diseases, but public health and medicine started to intersect almost immediately. The Roman empire dominated not only because of its advanced weapons of war, but also — and arguably more importantly — because of its aqueduct systems and access to clean water.4-6 Public health and political initiatives coming from physicians, often the people in the best position to understand an issue and its implications on human life, continue to have broader reach than one doctor can ever have on the treatment of individual patients.

In our modern world, the ultimate responsibility of identifying, implementing, and enforcing public health initiatives falls squarely on governments, ultimately intertwining physicians with politics. In the U.S., with the ACA expanding Medicaid, our very livelihood is even more dependent on the government and the specific policies it enacts and enforces, with real implications for our patients.7 These are inescapable realities; medical societies (including our own) have huge wings devoted to lobbying the government. How can we argue that practicing medicine today isn’t inherently political?

You’re still skeptical. You believe as doctors we should only deal with the known facts, and what’s in front of us; you think we owe it to our patients to be anything but political. Such a point of view isn’t without merit. But where do we start drawing the line between medical and political? These two areas are so intertwined, and it can interfere with open, honest discussion of issues.

Is gun control political or medical? It’s both.

If you work in an ED where no one gets shot, whether self-inflicted or inflicted upon them, then I can see how this might appear to be a foreign idea, but for those of us who treat the victims of gun violence on a regular basis, this is a medical problem confronting our patients no different than substance use, hypertension, or diabetes, and it requires the same focus on intervention, treatment, and prophylaxis.

Because of research and advocacy, seat belts, airbags, and smoke and carbon monoxide detectors are no longer optional but required. Why should we approach firearm injuries differently than our predecessors approached motor vehicle collisions, fire, and indoor air?

Kings County Hospital, where I train, was dubbed the “Knife and Gun Club” in the 1980s. Though the incidence of penetrating trauma has drastically reduced, in no small part to the strong gun control policies of Mayor Michael Bloomberg, we deal with victims of violence every day. It is important to note how many young minority men are disproportionately being killed and injured because of gun violence. If you work in an area serving minority populations, it is even more important to advocate for policies to address the social determinants of health.

I was involved in my medical school’s White Coat For Black Lives movement, and I think this is something we should all hold close to our hearts as providers.8-10 To try to prevent the continued cycle of violence in our predominantly black community, one of our amazing attendings, Dr. Robert Gore, runs the Kings Against Violence Initiative (KAVI), a youth intervention program. It’s the same concept as programs that aim to prevent diabetes through education and outreach. It’s aimed at controlling the disease at home, rather than waiting until critical illness arises. Violence is a disease, and we as physicians can play a role in treating and any all disease of the mind, body, and community.

Is it political when I ask patients about their smoking or substance use? Is it political when I talk to patients about their access to medications and physicians based on their insurance? Or what about when I talk to patients in the ED about stresses in their life, including concerns about their immigration status in this rapidly changing and fraught political atmosphere? ACEP has even taken a political stance on the Trump Administration’s Public Charge policy for immigrants, saying it will hurt our patients and discourage them from seeking care.11

We are not just black boxes seeing, treating, and dispo-ing patients. We have to look at what brings our patients in to truly treat them and our communities. I surely think I’m correct in my opinion,12 and though I don’t think there is need to do unique-to-the-U.S. research to come to the same answer other countries have discovered, I am open to having this discussion with my colleagues who might disagree with me in a mature and thoughtful manner. I think we would all benefit from an open and mature discussion. To simply shut down discussion because it is a politically charged topic will get us nowhere and will only hurt our patients.

It shouldn’t require us to have our own family affected by something to motivate action and discussion, but now it’s personal, and when one of our own is a victim of gun violence, we will have failed if we don’t respond. This doesn’t mean we all need to agree, but we should all agree to discuss the topic and to advocate for the health of our patients.


References
1. Jacobs J. Doctor Killed in Chicago Was Committed to ‘Serving the Underserved’. The New York Times. 2018.
2. Haag M. Doctors Revolt After N.R.A. Tells Them to ‘Stay in Their Lane’ on Gun Policy. The New York Times. 2018.
3. Council on Foreign Relations. U.S. Gun Policy: Global Comparisons. https://www.cfr.org/backgrounder/us-gun-policy-global-comparisons.
4. Delile H, Blichert-Toft J, Goiran J-P, Keay S, Albarède F. Lead in ancient Rome’s city waters. Proc Natl Acad Sci U S A. 2014;111(18):6594-6599.
5. Boston University School of Public Health. The Evolution of Epidemiologic Thinking http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_History/index.html.
6. Badash I, Kleinman NP, Barr S, Jang J, Rahman S, Wu BW. Redefining Health: The Evolution of Health Ideas from Antiquity to the Era of Value-Based Care. Cureus. 2017;9(2):e1018.
7. Kaiser Family Foundation. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review.
8. Chauhan P, Cerdá M, Messner SF, Tracy M, Tardiff K, Galea S. Race/Ethnic-Specific Homicide Rates in New York City: Evaluating the Impact of Broken Windows Policing and Crack Cocaine Markets. Homicide Stud. 2011;15(3):268-290.
9. Beard JH, Morrison CN, Jacoby SF, et al. Quantifying Disparities in Urban Firearm Violence by Race and Place in Philadelphia, Pennsylvania: A Cartographic Study. Am J Public Health. 2017;107(3):371-373. Available from:
10. Kaiser Family Foundation. Number of Deaths Due to Firearms per 100,000 Population by Race/Ethnicity.
11. ACEP. New Public Charge Proposed Policy Threatens Access to Emergency Care.
12.    Jehan F, Pandit V, O’Keeffe T, et al. The burden of firearm violence in the United States: stricter laws result in safer states. J Inj Violence Res. 2018;10(1):11-16.

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