We Just Need Our State & Federal Elected Officials to Care Enough to Implement Them

Like all of you, I watched and read about last week’s mass shooting with horror. Most Americans watched this recurring tragedy and said: “we need to do something”. In fact, there’s majority support for evidence-based interventions like universal background checks, Red Flag laws, a higher age requirement to buy firearms, and bans on semi-automatic assault rifles.

But sadly, there are also millions of Americans who apparently care more about a perceived threat to their arsenal than about the lives of schoolchildren or are simply indifferent to the carnage. Far too many politicians either don’t care about the firearm violence, are too far deep into the pockets of the gun lobby or are simply scared of losing power in their ‘safe’ districts where it’s popular to resist all firearm interventions.

As public health practitioners, we are in the best position to identify evidence-based practices that will save lives. Implementing those interventions, however, is political. This probably sounds defeatist, but at the federal level, it looks like there’s not enough political will to implement interventions to mitigate the carnage. In part, that’s because of people like Senator Sinema who are unwilling to waive filibuster to pass two evidence-based bills that have already passed in the US House of Representatives:

At the state level, the opportunities to implement helpful interventions are even fewer right now as current legislative leadership is more interested in passing laws that make things worse rather than better.

While the opportunities to pass laws at the federal and state level appear grim, that doesn’t mean that it will always be that way. When the tumblers finally click public health needs to be prepared to identify and recommend effective evidence-based interventions to inform policymakers. What does an evidence-based approach look like?  Below are some of the highlights.

Step 1 — Define the problem

Researchers and policymakers need reliable data to understand the scope and complexity of gun violence. There are many different types of gun violence, and each type often requires different prevention strategies. Collecting and distributing reliable firearm data is essential to combating gun violence through a public health approach.

Gun violence prevention researchers need reliable and timely data around the number of firearm fatalities and nonfatal injuries that occur in the United States each year. This data should include the demographics of the victim and shooter (if applicable), the location and time of the shooting, and the type of gun violence that occurred. Databases should classify the types of gun violence (suicides, intimate partner violence, mass shootings, interpersonal violence, police shootings, unintentional injuries) based on clearly defined and standardized definitions. This data should be made widely available and easily accessible to the public free of charge.

Step 2 — Identify risk and protective factors

The public health approach focuses on prevention and addresses population level risk factors that lead to gun violence and protective factors that reduce gun violence. A thorough body of research has identified specific risk factors, both at the individual level and at the community and societal level, which increase the likelihood of engaging in gun violence.

At an individual level, having access to guns is a risk factor for violence, increasing the likelihood that a dangerous situation will become fatal. Simply having a gun in one’s home doubles the chance of dying by homicide and increases the likelihood of suicide death by over three-fold. Other individual risk factors closely linked to gun violence include: a history of violent behavior, exposure to violence, and risky alcohol and drug use.

Community level factors also increase the likelihood of gun violence. Under-resourced neighborhoods with high concentrations of poverty, lack of economic opportunity, and social mobility are more likely to experience high rates of violence. These community level factors are often the result of deep structural inequities rooted in racism. Policies and programs should mitigate risk factors and promote protective factors at the individual and community levels.

Risk factors for suicide include easy access to lethal means, family history of suicide, previous suicide attempt(s), a history of mental illness, a history of risky alcohol or substance use, feelings of hopelessness or isolation, and others. By identifying these risk factors and thus further defining who is at risk, we can more effectively develop strategies to address these risk factors and prevent firearm suicide.

Step 3 — Develop and evaluate prevention strategies

Policymakers and practitioners must craft interventions that address the risk factors for gun violence. These interventions should be routinely tested to ensure they are effective and equitable; rigorous evaluations should be conducted on a routine basis.

The foundation for effective gun violence prevention policy is a universal background check law, ensuring that each person who seeks to purchase or transfer a firearm undergoes a background check prior to purchase.

Universal background checks should be supplemented by a firearm licensing system, which regulates and tracks the flow of firearms, to ensure that firearms do not make it into the hands of prohibited individuals.

Building upon this, policymakers can create interventions that target behavioral risk-factors for gun violence (e.g., extreme risk) and they can push for policies that address community risk factors that lead to violence (e.g., investing in community-based violence prevention programs).  Extreme risk or ‘Red Flag’ laws are also an effective prevention tool. These evidence-based laws take risk factors for harm to self or others into account and allow family members and/or law enforcement to petition a court to temporarily remove firearms until the period of heightened risk has passed.

A higher age requirement to buy firearms is an effective way of delaying the purchase of firearms until the maturation of the prefrontal cortex occurs (at age 25), reducing the frequency of impulse purchases that result in homicide, suicide, and mass killings. Banning the sale of assault rifles mitigates the scale of mass shootings when they occur (although the number of assault rifles in the possession of Americans has already gone from 400,000 to more than 20,000,000 since the assault rifle ban ended in 2004).

Based on the information gathered in the first two steps, public health professionals, policymakers, and others create data-driven interventions. These include policies and programs that address the risk factors and root causes of gun violence and target solutions to best serve at-risk populations.

Step 4 — Ensure widespread adoption of effective strategies

Firearm violence prevention public policy is only effective if they are properly implemented, and people understand how to use them. Implementation and evaluation of these initiatives should be conducted at the federal, state, and local levels as applicable.

For firearm suicide prevention, this means training the proper stakeholders, such as law enforcement and judges, and ensuring that new policies and programs to prevent firearm suicide — like extreme risk laws — are being properly adopted.

AzPHA’s Action Plan

For our part, AZPHA is in the process of providing a paid internship to a student to characterize the extent of firearm violence in Arizona. We believe we must do this because we have no confidence that the Arizona Department of Health Services (under current leadership) is willing to do so. The scope of work is to essentially provide an epidemiological and evidence-based recommendations for Steps 1, 2 and 3 above (focusing on state-level data and interventions):

  • Step 1 — Define the problem
  • Step 2 — Identify risk and protective factors
  • Step 3 — Develop and evaluate prevention strategies

Editorial Note: The continuing violence in Arizona and the U.S is disturbing and tragic and much of it is preventable. As public health professionals, we’re unable to take on the entire problem because implementing the solutions requires electing enough persons to public office at the state and federal level that care about this problem enough to implement policy interventions. But we can, and will, play a role in informing evidence-based policies that will work. We can also all be committed to supporting candidates for state, federal and local offices that share our values.

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