Dr. Mandelbaum Explains to Medscape Why Physicians Must Speak Out for Gun Control

An Old Problem Grows Worse

I got my first lesson in America's gun problem one day during my residency, when a patient walked into the emergency department at Johns Hopkins Hospital, bleeding from a chest wound and waving a .44 magnum revolver. "I want help," he said, and squeezed off a round.

A nurse and I dove under a metal desk. As slugs smashed into the desk and the wall behind it, I asked myself why this was happening. I'm still searching for an answer.

As physicians, we will always have to try to patch up the people who survive gun violence. But as professionals dedicated to preserving life, I believe that we also must speak out for gun control.

In just over 5 months, 101 individuals have died in massacres perpetrated by people with overwhelming firepower in their hands.

• On October 1, 2017, a gunman armed with multiple guns including ten AR-15 rifles shot some 1100 rounds into the crowd at a Las Vegas concert, killing 58 people.
• On November 5, 2017, a gunman used his Ruger AR-556 to murder 26 people at the First Baptist Church in Sutherland Springs, Texas.
• On February 14, 2018, a gunman armed with an AR-15 and multiple magazines killed 17 people at Marjory Stoneman Douglas High School in Parkland, Florida.

These are only the most recent mass shootings to take place in the United States; they are occurring now with horrifying regularity. They will continue until we take action. And they are only a small part of the problem with gun violence in this country. Thirty-five thousand of us die by guns every year,^[1] mostly by smaller-scale murders, suicides, and accidents involving handguns.^[2] It is not normal. We shoot each other at roughly 20 times the rate found in other high-income countries.^[3]

As a physician, I like to look at a social problem as I would examine any malady—by making a diagnosis, analyzing the pathogenesis, and recommending an intervention. In this case, the diagnosis is clear. We have created a public health hazard by allowing virtually everyone access to military-grade weapons. These weapons are being used to kill innocent people, including our children.

The Second Amendment, Clarified

What's the pathogenesis of this public health hazard? It started in 1791 when the Second Amendment to the US Constitution was ratified. It says: "A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed."

At that time, the fledgling nation had no standing army. The founders believed that local militias should respond to crises such as a sudden invasion by a foreign power. These militias would be composed of ordinary citizens, most them living in rural places, who would arm themselves with the weapons they kept at home for hunting. No records from the time suggest that the framers wished to protect an individual's right to weapons.^[4]

In the centuries since then, the state militias were essentially incorporated into the federal standing army. Military weapons have evolved into a lethal firepower the framers of the constitution never imagined. And with most people in cities and suburbs, population density makes the misuse of these weapons even more dangerous.

Some still argue that individuals need guns to protect against encroachments of civil liberties by the federal government. But it is no longer reasonable to imagine that rifles and handguns are any match for the tanks, bombers, and missiles of the US military, and no person in their right mind would allow individuals access to that kind of armament.

At the same time, we are grappling with a huge problem of untreated mental illness. For example, in California state prisons, 29% of the population is mentally ill.^[5] We are simply not keeping up with the vast need for diagnosis and treatment of psychosis, depression, anxiety, and other disturbances that can lead a person to an impulsive act of violence.

Recognizing such changes, local, state, and federal governments have been writing laws about firearms for 2 centuries. And the US Supreme Court has held that the Second Amendment does not confer a "right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose."^[6]

Physicians Must Actively Pursue Solutions

Our laws have not kept up with the rapid changes in the circumstances of gun use. Guns have always played an important part in our popular culture, and many people revere them as the ultimate symbol of individual rights. Thus, even the most modest proposals to restrict the use of guns face fierce opposition. We can and should uphold the right to responsible use of guns while restricting the irresponsible use of them, just as we uphold the right to drive automobiles but also restrict their use to trained adults who do not drive while inebriated.

What role can physicians play in this intervention? That day in the emergency department, when bullets rained onto the wall behind me, I got a full taste of the risk physicians face when working with desperate people. But our obligation goes beyond defending our personal safety. Our children are our most sacred resource. We must protect them from physical and emotional harm at all costs. If we do not actively pursue solutions to this societal malady, we will seem to condone it.

As public health leaders in our communities, we must speak up for intelligent restrictions on gun use, just as we speak up about vaccination, fluoridation, and sanitation, wherever we can gain access to a public forum—in newspaper op-eds, at town halls, in blogs, and in community newsletters.

I support the 2015 call to action from the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, American Psychiatric Association, American Public Health Association, and American Bar Association.^[7] This document lays out common-sense policies that I believe could save thousands of lives every year:

• Physicians should be able to discuss firearms with their patients. At times, the primary care physician is the only person in a position to recognize an individual's risk for suicide or murder. Just as we must be aware of our patients' risk for addiction before we prescribe opioids, so must we take into consideration their risk of harming themselves and others. When patients express a desire to hurt someone, we should be able to follow up by asking about their access to firearms and, if the danger seems imminent, contact family members or law enforcement. Laws that limit these discussions are detrimental to the public health. By the same token, no law should force a physician to report information a patient has made in confidence.
• More extensive resources should be devoted to awareness, diagnosis, and treatment of mental illness.
• People who want to buy firearms should undergo criminal background checks, including for sales by gun dealers, sales at gun shows, and private sales between individuals.
• Civilians should not be able to buy weapons designed to kill large numbers of people in a very short amount of time.
• Congress should provide more funding and not restrict research into firearm violence by the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies.

Those measures could have prevented me from facing the longest half minute of my life, under that desk in the emergency department. As we cowered there, our assailant alternately called for help and fired his gun while we shouted to him that we would like to help him if he would put down the weapon. Finally, he dropped the revolver and followed us into the trauma room, where he went into cardiac arrest. We opened his chest, fished out the bullet, and resuscitated him.

Decades later, I am still fishing bullets out of bodies. But now I have decided to speak out.

References

1. Bower E. American deaths in terrorism vs. gun violence in one graph. CNN.com. October 3, 2016. ArticleAccessed March 28, 2018.
2. Woolfolk J. Guns and deaths in America: The numbers. The Mercury News. February 28, 2018. ArticleAccessed March 28, 2018.
3. Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011;70:238-243. Abstract
4. Waldman M. How the NRA rewrote the second amendment. Politico. May 19, 2014. Article Accessed March 28, 2014.
5. Sewell A. Mentally ill inmates are swamping the state's prisons and jails. Here's one man's story. Los Angeles Times. June 19, 2016. Article Accessed March 28, 2018.
6. Supreme Court of the United States. District of Columbia, et al. v Heller. Decided June 26, 2008. ArticleAccessed March 28, 2018.
7. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-516. Abstract

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