America’s Gun Violence Crisis:
A Time for Action

“It is far more difficult to look in the mirror and see what we have or haven’t done. All of us have allowed this crisis to grow.”

The simmering frustration over gun violence reached a boiling point for Northwell Health President and CEO Michael Dowling in August 2019. On consecutive days that month, mass shootings claimed the lives of 23 people in El Paso, TX, and nine in Dayton, OH, and injured 40 others. While the 417 mass shootings that occurred that year represented only about one percent of all gun-related deaths in the US, what was especially troubling to Mr. Dowling — beyond Congress’ unwillingness to undertake any meaningful action to enact common-sense gun safety legislation — was the continued silence about gun violence among the nation’s health care leaders.

After all, the health care industry has proven its ability time and again to meet the challenges of the most daunting public health crises in this country, as it would demonstrate just six months later with the start of the COVID-19 pandemic. About 40,000 people were dying every year from gunfire, including murders, accidental shootings and suicides, yet there was no sense of outrage among hospital and health system CEOs who are responsible for caring for 329 million Americans.

Marisol Martinez, left, a student at Marjory Stoneman Douglas High School in Parkland, FL, and fellow activist/singer Payton Francis of Operation Respect, an organization dedicated to advancing the social and emotional growth of young people, perform at Northwell’s inaugural Gun Violence Prevention Forum in 2019.

Mr. Dowling vented his frustration in a paid op-ed published in the August 22, 2019 national edition of The New York Times, imploring health care leaders to raise their voices to stop the bloodshed.

“It is easy to point fingers at members of Congress for their inaction, the vile rhetoric of some politicians who stoke the flames of hatred, the lax laws that provide far-too-easy access to firearms, or the NRA’s intractable opposition to common sense legislation,” he wrote. “It is far more difficult to look in the mirror and see what we have or haven’t done. All of us have allowed this crisis to grow.”

Annual forum mobilizes health care leaders

Less than four months later, in December 2019, Northwell convened its first Gun Violence Prevention Forum, at which Mr. Dowling pledged $1 million to help mobilize health care providers to combat gun violence as a national public health crisis.

More promising news followed days later, when Congress reached an agreement to provide federal funding for gun violence research for the first time in more than 20 years. The federal government had stopped funding gun violence research in 1996 when Congress passed a rule called the Dickey Amendment, which prevented the US Centers for Disease Control & Prevention (CDC) from using funds “to advocate or promote gun control.”

NIH grant helps screen at-risk patients

The spending bill approved by Congress in December 2019 and signed by then-President Trump included $25 million for research, to be split evenly between the CDC and the National Institutes of Health (NIH). Less than a year later, in September 2020, Northwell became the recipient of a $1.4 million NIH grant to establish and implement a first-of-its-kind protocol to universally screen patients at risk of firearm injury.

Mr. Dowling vented his frustration in a paid op-ed published in the August 22, 2019 national edition of The New York Times.

Center for Gun Violence Prevention

As part of an ongoing effort to advance gun safety, education, violence prevention and research, Mr. Dowling established the Center for Gun Violence Prevention at Northwell in February 2020, appointing pediatric trauma surgeon Chethan Sathya, MD, as director. “I firmly believe that health care leaders have a social responsibility to try to stop the mindless bloodshed caused by firearms-related violence in this country, just as we respond aggressively to health crises like vaping, the flu or the new coronavirus that is causing worldwide panic,” Mr. Dowling said in announcing the new center on February 26, days before the first wave of COVID-19 swept through the New York area.

Shootings spike during pandemic

While the ensuing pandemic would preoccupy health care providers for many months to come, it certainly did not stop the violence on America’s streets. On the contrary, the number of gun-related deaths spiked to a record 43,654 in 2020, including 24,156 suicides and 611 mass shootings (defined as four victims shot in a single incident). The record number of gun deaths was broken again in 2021, spiking to 44,917, according to the Gun Violence Archive, an independent research and data collection organization that has been tracking gun violence since 2014.

Opening a dialogue on best practices

Looking to keep health care professionals engaged in identifying ways of curbing the surge in shooting deaths and injuries, Northwell established a Gun Violence Prevention Learning Collaborative, which began holding virtual meetings in April 2021. More than 500 health care professionals from 35 states have become involved in this interactive, apolitical forum, enabling them to share ideas and best practices that have proven effective in mitigating street violence and suicide.

In July 2021, Northwell Health President & CEO Michael Dowling and other representatives met with LIFE Camp co-founder Erica Ford, left, and visited the organization’s “peace mobile,” a mobile trauma unit that provides therapeutic wellness, conflict resolution and mediation training services to communities throughout the city that have been impacted by gun violence.

The promise of violence intervention programs

Many of the participants in the Learning Collaborative, as well as past attendees of Northwell’s Gun Violence Prevention Forums, would join more than 1,400 other health care professionals in signing a letter co-authored by Mr. Dowling and 17 other health system CEOs in July 2021, calling on Congressional leaders to support President Biden’s plan to invest $5 billion in hospital- and community-based gun violence intervention programs.

Federal funding is an important next step in enabling hospitals and health systems to develop intervention plans and work with local community-based organizations.

“The health care industry has a unique ability and responsibility to tackle the epidemic of gun violence,” said Mr. Dowling. “Like with COVID-19, we can stem the gun violence crisis if we take a public health approach to preventing and treating firearm injury and death. That means collecting data to understand the scope of gun violence, conducting research to identify risk factors, and developing interventions that keep our patients and communities safe.”

At a time when gun violence rates are surging in cities across the country, there’s no better time to double down on the conviction that words, thoughts and prayers alone are not enough.

Asking the right questions

Doctors routinely ask patients about their diet and exercise habits, whether they smoke, drink alcohol or use other substances, all in a perfectly reasonable assessment of an individual’s health risks. But what if physicians also asked about guns?

Beginning in November 2021, clinicians at three Northwell Health hospitals began adding another set of questions to that routine list in an effort to determine whether patients’ health or safety is at risk from gun violence. Question one: “Do you have access to a firearm within or outside your household?”

The screening protocol, introduced at Staten Island University Hospital, South Shore University Hospital in Bay Shore, NY, and Cohen Children’s Medical Center (CCMC) in New Hyde Park, NY, is part of a research project to study gun violence prevention, and to identify and intervene with those who may be at risk of firearm injury.

“The opportunity to discuss firearm injury risk and the potential for harm to our patients and their families had not been part of our clinical repertoire, despite being a known public health issue,” said Chethan Sathya, MD, a pediatric trauma surgeon at CCMC and director of Northwell’s Center for Gun Violence Prevention.

The research study is funded by a $1.4 million grant awarded in 2020 by the National Institutes of Health (NIH). Notably, the grant was among the first awarded by the federal government in nearly a quarter-century, since the 1996 passage of a Congressional budget provision called the Dickey Amendment, which mandated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention (CDC) may be used to advocate or promote gun control.” Lobbied for by the National Rifle Association, the Dickey Amendment, though vaguely worded, kept the CDC and other federal agencies from funding gun violence research for fear they would be punished financially.

“The opportunity to discuss firearm injury risk and the potential for harm to our patients and their families had not been part of our clinical repertoire, despite being a known public health issue.”

The freeze was finally lifted in December 2019, when Congress approved a spending bill that included $25 million for gun violence research.

In 2021, Northwell trained more than 200 physicians, nurses, social workers and other clinicians on the screening module. The goal is to “normalize the conversation around gun safety, similar to other health risk factors that are part of routine care,” said Sandeep Kapoor, MD, assistant professor of medicine, emergency medicine and science education at the Zucker School of Medicine at Hofstra/Northwell. Rather than waiting until someone shows up at a hospital with a firearm-related injury, the goal is early intervention “It’s all about safety, prevention and harm reduction,” said Dr. Kapoor. “It’s not about the Second Amendment.”

In addition to asking patients whether they have access to a firearm, adults and adolescents (ages 12–17) are asked questions designed to determine risk of future violence: “In the past six months, including today, how often have you heard guns being shot or had someone pull a gun on you?” Teens are also asked if they have gotten into serious physical fights, or if their friends carry knives, razors or guns.

The use of these evidence-based screenings allows the clinical team to understand if the patient is at risk for violence or firearm injury. Based on the patients’ responses, they are offered an opportunity to further explore and discuss what changes can be incorporated into their lives to reduce the level of risk. Trained team members skilled in motivational interviewing foster an environment for safe, non-judgmental and non-confrontational dialogue. Based on the discussion, patients may be offered firearm safety locks, information and resources for storage and safety training, and connections to community-based violence interrupter programs that serve as a longitudinal support structure for patients.

The clinicians are trained to underscore that the screening protocol is not intended to cast judgment on those who are gun owners or to report them to authorities, but simply to determine if firearms are stored properly and whether there are any safety risks.

Considering that well over half of all gun-related deaths are suicides (24,090 in 2021), hundreds of which involve young people, it’s especially important to ensure that children do not have access to firearms, said Dr. Kapoor. “By universally asking about access and violence risk, we can help prevent future events and create safer environments in the home and our communities,” he said.