john p. may, md, facp armor correctional health services american correctional association congress...

Physician’s Role in Gun Violence Prevention

John P. May, MD, FACPArmor Correctional Health Services

American Correctional AssociationCongress of CorrectionsHarbor Point, MarylandAugust 10, 2013

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Public Health Approach

Injury is no

accident

The Public Health Approach: Multidisciplinary Scientific Method Directed to Prevention

Individual Behaviors

andAttitudes

Disease or Injury

Socialand

Physical Environments

Intentional◦ Assault◦ Suicide◦ Homicide

Unintentional◦ Motor Vehicle Crash◦ Sport injury◦ Slip and fall

Types of Injury, examples

Leading Injury Deaths, USA, 2010

Motor Vehicle Crash Firearms

MVC0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Firearms0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Reducing Injury of Motor Vehicle Crashesdesignated driver, airbags, shatter resistant windshields, highway lighting, roadway design and repair, seatbelt campaigns, child restraint seats, trauma systems

Firearm Mortality by Country

USA

Finla

nd

Switzer

land

Franc

e

Belgi

um

Portu

gal

Austri

aIs

rael

Italy

Canad

a

Norway

Sweden

Irela

nd

Denm

ark

New Z

eala

nd

Germ

any

Austra

lia

Spain

Nethe

rland

s

Engla

nd&W

ales

Scotla

nd

Japa

n

S Kor

ea0

1

2

3

4

5

6

7

8

9

10

De

ath

s p

er

10

0,0

00

Pe

rso

ns

11,078 Homicide19,392 Suicide1,201 Other

Firearm Deaths, USA 2010

International Rates of Homicide2010, World Health Organization

USA India Lebanon Finland Israel Ireland Italy Sweden Japan0

1

2

3

4

5

6

16,259 Homicides• 77% male (perpetrator 89% male)• 50% black, 46% white and hispanic, 4% other• 67% killed by firearms, usually handgun• Most victims under influence of alcohol or drugs• Most during arguments or fights, not violent crime• When perpetrator is known:

54% known to victim 25% family member

Homicide, USA, 2010

A woman’s risk of domestic homicide

7 times more likely, if gun in the home.

Source: Bailey, JE, et al., Archives of Internal Medicine, 1997

RISKS OF HOMICIDE

• Usually killed by someone known to victim

• Usually killed by someone of the same race

• Usually killed during an argument or fight

• Usually killed in an environment of drugs or alcohol

• Usually killed with a handgun

In urban areas…More than half of homicide victims had prior criminal records

In 1st year after gun purchase, suicide is

leading cause of death.Source: Wintemute GJ, Parham CA, Beaumont JJ, Wright M, and Drake C. Mortality among recent purchasers of handguns. NEJM, 1999.

SUICIDE RISK AND GUN OWNERSHIP

Source: Kellerman AL, Rivara FP, Somes G, et al., NEJM 1992

1

3

5.8

0

1

2

3

4

5

6

7

Handgun Long Gun No Gun

1

3.3

9.2

0123456789

10

Loaded Gun Unloaded Gun No Gun

NoIncreased

Risk

Odds Ratio

NoIncreased

Risk

In 1st week after gun purchase,suicide risk increases 57 times.

Source: Wintemute GJ, Parham CA, Beaumont JJ, Wright M, and Drake C. Mortality among recent purchasers of handguns. NEJM, 1999.

Source: Kellerman AL, Rivara FP, Somes G, et al., NEJM 1992

In homes with firearms,a gun was the method chosen in 86% of the

cases. In homes where firearms were not

usually kept, only 6% of the cases killed

themselves with a gun.

Source: Kellerman AL, Rivara FP, Somes G, et al., NEJM 1992

Guns Kept in the Home:Suicide Risk 5 Times

Greater

15-19 20-24 25-34 34-44

Unintentional Injuries

(40.9%)

Unintentional Injuries

(41.7)

Unintentional Injuries

(26.1%)

Unintentional Injuries

(22.9%)

Homicide

(20.1%)

Homicide

(18.1%)

Suicide

(14.7%)

Heart Disease

(16.6%)

Suicide

(16.5%)

Suicide

(16.1%)

Homicide

(11.9%)

Cancer

(11.6%)

Leading Causes of Deathby Age Group, All Males, USA 2009www.cdc.gov/nchs/deaths.htm 2013

15-19 20-24 25-34 34-44

Homicide

(50.4%)

Homicide

(49.2%)

Homicide

(32.8%)

Heart Disease

(20.7%%)

Unintentional Injuries

(20.9%)

Unintentional Injuries

(17.9%)

Unintentional Injuries

(19.7%)

Unintentional Injuries

(14.1%)

Suicide

(6.5%)

Suicide

(7.8%)

Heart Disease

(9.3%)

Homicide

(11.3%)

Leading Causes of Deathby Age Group, Black Males, USA 2009

Leading Causes of Death, USA, 2009African American Males, Age 15-34

Homicide MVC Heart Suicide0

500100015002000250030003500400045005000

Goal of Healthy People 2010 

"The future health of the nation will be determined to a large extent by how effectively we work with communities to reduce and eliminate health disparities between non-minority and minority populations experiencing disproportionate burdens of disease, disability, and premature death."                               

~ Guiding Principle for Improving Minority Health

Eliminating Racial and Ethnic Health Disparities

A Role for the Primary Care Physician in Counseling Young African American Men About

Homicide Prevention

May JP, Martin KL. Journal of General Internal Medicine, July 1993; 8:380-382

The number one cause of death for African American men age 15-34: Homicide

THE PROBLEM:

Is there a role for the primary care physician in preventing death by homicide?

THE QUESTION:

There is a role for the primary care physician in preventing homicide similar to other preventive medicine issues.

THE HYPOTHESIS:

THE STUDY:

53 African American males, aged 15-34, who presented to the Cook County Hospital Ambulatory Screening Clinic were treated for their presenting complaint by the study’s resident physician.

During the encounter, the physician counseled each patient about six preventive medicine issues: smoking, alcohol, drugs, safe sex, seat belts, and firearms.

THE STUDY

After the encounter the patients participated in a short post-visit interview which evaluated their impression of the visit and the issues which they recalled.

THE STUDY (Con’t):

Question 1: Before today have you been to a doctor in

the past six months?

YES 31 (58.5%) NO 22 (41.5%)

THE RESULTS:

Question 2: Have you ever tried to change a behavior

that could be harmful to your health because a doctor recommended it:• YES 17 (32.1%)

• YES 21 (37.7%) but not because of a physician’s recommendation

• NO 16 (30.2%)

THE RESULTS:

Question 3: Were you satisfied today that your problem

was taken care of?

YES 53 (100%) NO 0 ( 0.0%)

THE RESULTS:

Question 4:• Which health care issues did the doctor discuss

with you?

THE RESULTS:

GUNS SAFE SEX ALCHOHOL SMOKING DRUGS SEAT BELTS0

20

40

60

80

100

120

PATIENT RECALL OF PREVENTIVE HEALTH ISSUES DISCUSSED WITH DOCTOR

Question 5: Which of these is most important?

THE RESULTS:

ALL GUNS SAFE SEX DRUGS SMOKING ALCOHOL SEAT BELTS0

5

10

15

20

25

30

35

40

14.7

34.4

31.1

11.5

4.93.7

0

Issue Viewed as Most Important by Patient

ISSUE(S) VIEWED AS MOST IMPORTANT BY PATIENT

Question 6: Do you think it is important for a doctor to

talk with you about guns?

YES 43 (81.1%) NO 10 (18.9%)

THE RESULTS:

Question 7:• Do you think anything the doctor said will change

the way you try to take care of yourself:

Yes 50 (94.3%) No 3 ( 5.7%)

THE RESULTS:

Question 8:• What do you think you can do to reduce your risk

of being shot?

THE RESULTS:

avoid wrong crowds-live a clean life-don’t respond to aggression-avoid wrong areas-don’t own a pistol-keep a positive attitude-avoid gangs-don’t look for trouble-get a car-keep out of trouble-don’t stay out late-bullet proof vest-mind your own business-change entire life to positive surroundings-hang out with good people-avoid drug spots-don’t wear hats-don’t go out much-be careful who you talk to-stay off street corners-don’t sell drugs-be careful-avoid alcohol-be careful who you talk to-keep your mouth shut-avoid loan sharks-keep to yourself-stay in school-avoid conflicts-stay in your own territory-call police-don’t commit crimes-pray-never fight more than one person

ACTIVITIES MENTIONED BY PATIENTS WHICH REDUCE THEIR CHANGE OF BEING SHOT

Question 9:• Do you believe that you have any control in

whether or not you are shot?

Yes 16 (30.2%) No 37 (69.8%)

THE RESULTS:

Summary Discussing firearms with the population

most at risk was accomplished in a brief period of time and was well received. Patients recalled and were impacted by the issue of firearms more than any other issue.

THE RESULTS:

Not discussing firearms with the population most at risk represents a missed opportunity. Patients are interested in the topic, impacted by the discussion, and identify certain behavior modifications as preventive. Health care providers can and should be part of the solution to the problem of homicide.

THE CONCLUSIONS

Jail and Prison

Incarceration may be the biggest risk factor for prediction of violent-related injury

How many persons are wounded each year with firearms?

National Electronic Injury Surveillance System (NEISS).

2129 male detainees were queried at intake of 5 jails of different geographic locations. Six of the 2129 refused to interview. Of the men completing the survey, 307, or 14.5% reported having been shot. Among the detainees who had been shot, 277 (91%) reported going to the hospital the most recent time they were shot

Do Criminals Go to Hospital after being Shot?May JP, Hemenway D, Hall A. Injury Prevention 2002;8:236-238

Site of Jail Facility Number Percentage

Baltimore, MD 58/341 17%

Lawrenceville, GA 9/80 11%

Las Vegas, NV 68/518 13%

Santa Rita, CA 153/969 16%

Summit County, OH 19/215 9%

Total 307/2123 14.5%

Detainees reporting prior gunshot wounds

Source: Health Service Interviews, 1999

Prior Gunshot Wounds in Detainees of a Large Urban JailCook County Department of Corrections, 1995 May JP, Ferguson MG, Ferguson R, Cronin K. Journal of Health Care for the Poor and Underserved. 1995;6(2):162-175.

A survey of 582 randomly selected detainees entering the Cook County Department of Corrections during the summer of 1994 found that 51 percent had previously entered hospitals for violence-related injuries, and 26 percent survived prior gunshot wounds.

Prior Gunshot Wounds in Detainees of a Large Urban JailCook County Department of Corrections, 1995 May JP, Ferguson MG, Ferguson R, Cronin K. Journal of Health Care for the Poor and Underserved. 1995;6(2):162-175.

Risk factors◦ Access to a gun◦ Gang-related tattoo◦ Witnessed violence at

early age◦ Prior STI◦ Prior incarceration

Original Article

When Criminals Are Shot: A Survey of Washington, DC, Jail Detainees

June 28, 2000John P. May, MD, FACP, Medical Director, Fulton County Jail, Atlanta, Georgia

• David Hemenway, PhD, Professor on Health Policy, Harvard School of Public Health, Boston, Massachusetts Roger Oen, MPH, Medical Student, George Washington University School of Medicine and Health, Washington, DC

Khalid Pitts, MPH, Quality Assurance Coordinator, Central Detention Facility, Washington, DC Medscape General Medicine 2(2), 2000. © 2000 Medscape Portals, Inc

Abstract and Introduction

AbstractIntroduction: Criminals are at high risk of being victims of violence, but little is known about their victimization.Methods: A screen of Washington, DC, detainees found that 1 in 4 had been wounded in events that appear unrelated to their incarceration. Extensive interviews were conducted with 79 men entering the city jail from March through June 1997; the men reported 93 prior events in which they had been shot within the past 5 years.Results: Eighty-three percent had personally witnessed someone being shot, and 46% had a family member killed with a gun. In the incidents in which they were shot, most were victims of robberies, assaults, and crossfires. The shootings were serious -- 35% were hit by more than 1 bullet, more than 90% went to the hospital, and 40% still had some disability from the wounds. These detainees report being shot by other criminals rather than by law-abiding citizens. Ninety percent would prefer to live in a world without easy access to firearms.Conclusion: These young men live in a violent world of gunplay. The overwhelming majority would prefer that firearms were not so readily available.

Robbery 24%

Crossfire 21%

Assault 21%

Retaliation 18%

Argument 6%

Accident 6%

Police 4%

Circumstance of Shooting,N=93

Hit with > 1 bullet (n = 88) 35%

Hit in head or torso (n = 87) 54%

Bullet(s) still in body (n = 89) 34%

Carrying gun when shot (n = 90) 8%

Detainees with prior GSW

The respondent was 16 years old, standing on a corner in an unfamiliar part of town near a group that was selling cocaine. He was high on PCP. Suddenly, shots started to "pour out" toward the crowd. He saw 2 or 3 people shooting guns. He started to run. It all happened so fast, but he doesn't believe that they were aiming for him. He felt "something like a rock" hit him in his leg as he ran. The bullet is still in his leg. He never went to a hospital. He has never liked guns, and had no desire to have one then, or now. He says, "I'm not into guns...I'm only into getting high." He wishes it were harder for people to get guns. His 19-year-old cousin was killed by a gunshot wound to the back of the head during an argument.

Crossfire

The respondent was 17 years old when he was shot. He was high on PCP and walking down a familiar street when a stranger approached him and pulled a gun. The person asked for money, which the respondent gave him, but still the robber shot him as he ran. He was hit in the right shoulder with a .38 caliber bullet. He spent 2 days in the hospital. He believes that if he had a gun during the robbery, the robber would have killed him so that he couldn't retaliate. The shooting, however, makes him more likely to carry a gun because he believes it would protect him.

Robbery

The respondent was standing in an alley when he was approached by 3 strangers. They asked him for money, but he refused. He grabbed 1 of the strangers and wrestled him to the ground. He tried to run, but they pulled out guns. He was hit by 3 bullets from 2 different guns. The assaulters ran off in the other direction, and the respondent was able to flag the police, who called an ambulance

Robbery

The 17-year-old respondent was in a carry-out restaurant when suddenly 3 people wearing masks began shooting at him through the windows. The glass shattered everywhere, and he tried ducking. He "faked" that he had a gun by pointing his hand, trying to get them to stop. He wished that he had his real gun, which was stashed in some bushes not too far away. He did not know who these people were. A friend who was with him did not get hit. Ten to 15 bullets were fired, but only 1 struck him in the arm. He started carrying a gun with him, in part because his arm injury made it more difficult to run fast. He said, "All these 70s babies...all they think about is guns."

Assault

The respondent was 33 years old, sitting in a car, when he noticed 2 strangers in the rear view mirror. He attempted to drive away, but they started shooting. He was hit with 4 bullets in the head, 1 in the neck, and 1 in the hand. He spent 2 weeks in the hospital. He believes they were trying to shoot his brother, who was also in the car. He frequently has flashbacks about the event, and wishes he had his gun with him that evening to shoot back. When he was younger, he was frequently "caught up with guns and stuff" and admits to shooting at other people. Another brother of his had been shot in the back by police and died at age 29.

Assault

The respondent was 18 years old, walking down a familiar street, when 3 people came by in a car. He knew 1 of them as the brother of a woman who said she was pregnant with his baby. Suddenly all 3 pulled out guns and started shooting at him. Many bullets were fired, and 1 hit him in the back. He went to the hospital for treatment, but the wound was treated in the emergency room and he was released. He believes that if he had been carrying a gun, they would have been more likely to have "gotten him good."

Retaliation

The respondent was 17 years old when he got into a pushing and shoving fight with other youth at a "go-go club." The next day, he and a friend were walking to a car from a basketball tournament at his school. About 10 individuals approached them, and 1 pulled out a .357 Magnum and shot him in the chest. His friend put him in a car and drove him to the hospital. He had a collapsed lung and spent more than a month in the hospital.

Retaliation

The respondent was 22 years old and on the street. He started arguing with a guy he didn't know over a girl. He says it was "something real small, real dumb." They started pushing each other and the shooter pulled out an automatic handgun and shot him twice in the abdomen. He spent 3 weeks in the hospital and had major surgery. Now his digestive system is "messed up," and it is difficult for him to use the bathroom. He started carrying a gun after this event "because someone almost took my life. I need it for protection." He stated that his cousin retaliated and shot the person who had shot him.

Argument

The respondent was 17 years old and trying to buy ice cream at an ice cream truck when he was approached by a person he recognized, but did not know very well. This person began name calling, and it escalated into an argument. He was shot at close range with a .38 caliber handgun. He was hit by 3 bullets in the neck, chest, and leg. He states he was "dead on arrival" at the hospital but recovered after open heart surgery. The event left him with a partial stroke and weakness on one side of his body. He is now 19 years old and believes the threat of being shotby the police causes many people to carry

Argument

The respondent was 18 years old and was carrying a 9-mm semiautomatic handgun in his pants pocket. A "dude" appeared from around the corner and the respondent felt threatened. He grabbed for his gun, but it went off in his pocket. The bullet went into his right leg as the man ran away. He decided not to go to the hospital. He cleaned the wound himself at home, covered it with an ace bandage, and used a cane for walking. Four months later, the bullet came close to the surface, and he cut it out with a razor blade. The experience made him decide not to carry the gun anymore.

Unintentional

The respondent was 47 years old when he was shot unintentionally by his brother. The respondent is addicted to heroin, and he and his brother were outside. They began arguing because the respondent wanted to get some drugs. His brother had a gun and tried to scare him by shooting into the ground. The bullet ricocheted from the concrete and hit him. The bullet destroyed part of his stomach. He spent 40 days in the hospital and continues to have digestive problems.

Unintentional

The respondent was shot by the police when he was 25 years old. He was in an alley with someone who had a gun and was shooting it in the air. The respondent claims that he did not have a gun. The police came and shone a flashlight on him and shot him. He was hit once in the leg with a bullet from a 9-mm. He stayed in the hospital for 4 days under police custody. He says the incident makes him less likely to trust people because he believes the police were wrong for shooting him. He says he is now more likely to carry a gun for protection.

Police

The respondent was 20 years old and in an argument. Someone called the police, and the respondent fled, with a gun in his hand. Two officers chased him, and 1 fired a shot that hit him in the leg. It missed the bone, and he spent less than a day in the hospital.

(This same individual has been shot on 3 separate occasions)

Police

Gun Identification SurveyCentral Detention Facility, Washington DC, 1997Institute of Medicine

Percentage of Guns Correctly IdentifiedGun Identification SurveyCentral Detention Facility, Washington DC, 1997

15-24 20-24 25-29 30-34 35-39 40-44 45-49 50 - above

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Gun Features Most AdmiredIndiana Department of CorrectionsYear: 2000 Inmates Surveyed: 388

24 and younger: Rapid fire Way it looks Spits more rounds “auto” written on it Air holes, breather

25 and older: Accurate

Hits hard Stopping power Small Easy to conceal

The Cycle of Violence

Sims DW, Biuins BA, Obeid FN, Horst HM, Sorensen VJ, Fath JJ. Urban trauma: a chronic recurrent disease. J Trauma. 1989 Jul;29(7):940-946.

Violence behaves as a chronic disease with an ominous prognosis.

One study found that, among patients admitted to a trauma center for assault-related injuries, 44% had recurrent trauma and 20% were dead within 5 years.

The trauma of witnessing violent events can also impact a person’s life. Children who are exposed to violence, either as a victim or by witnessing a violent injury or death, can develop post-traumatic stress syndrome. Violent victimization can diminish a person’s sense of self, reduce hope for the future, and impair the ability to form trusting interpersonal relationships. Many youth, especially boys, who witness violence turn to weapon carrying for protection.

Witnessing Violence

Prisoner Rates of Death in USA

0

200

400

600

800

1000

1200

1400

GeneralPopulation

Prison Parole

Safer in prison than the streets

Fewer homicides in prison than streets

Higher parolee deaths: guns, car crash, HIV, drug overdose

May J. In Management and Administration of Correctional Health Care; Moore J., CRI 2003

SURGEON GENERAL’S WARNING: Smoking By Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight.

Public Health Approach toInjury Prevention

Handguns

Fatal

- AIDS - Use condoms - Do not share needles - Multiple sex partners increase risk

- Firearm Injuries - Lock all guns - Store ammunition separately - Guns in home increase risk

PUBLIC HEALTH ISSUES

Health ProblemExamples of Individual

Behavior and Attitude Changes

PUBLIC HEALTH ISSUES

- Improvement in sanitation, nutrition,housing

- Attention to overcrowded areas

- Creation of youth activity programs- Developing suicide prevention

networks- Address gun “machismo”

Health ProblemExamples of Social

Environment Modifications

- Tuberculosis

- Firearm Injuries

PUBLIC HEALTH ISSUES

Health ProblemExamples of Physical

Environment Modifications

- Motor vehicle crashes- Airbags- Roadway construction and lighting

- Metal detectors in schools - Improve lighting and limit

building entrances- Reduce accessibility of guns

- Motor vehicle crashes

- Firearm Injuries

Primary PreventionPrevent injury or disease before it happens

PUBLIC HEALTH ISSUES

- Vaccines - Conflict resolution training- Smoking education - Prevent access- Diet and exercise (locks, background checks)

- Counseling for alternation means of protection

Primary Prevention Firearms

PUBLIC HEALTH ISSUES

Secondary Prevention Minimizing the effects of disease or injury in progress

- Treating hypertension - Registration of guns- Smoking cessation - Bulletproof vests- Reducing air pollution - Less destructive firearm

power and ammunition

Secondary Prevention Firearms

PUBLIC HEALTH ISSUES

Tertiary PreventionResponding after the injury or disease has occurred

Tertiary Prevention Firearms

- Treating lung cancer- Coronary artery bypass- Chelation therapy for lead poisoning

- Trauma network - Spinal cord injury rehabilitation- Counseling programs for victims

Handguns, like cigarettes,

can be deglamorized.

Rx: Public Messages

Source: Chicago Project for Violence

Public Health and Individual Rights

 Smoke-free Environments

Mandatory Seat BeltsMotorcycle Helmets

Childhood ImmunizationsFirearms

• Child proofing

• Loading indicators

• Longer barrels

• Less destructive ammunition

• Prohibit semi-automatics

Rx: Product Liability Opportunities for Safety

• Personalized triggers

• Tracers on explosives

• Truth in advertising

• Control distribution

• Regulate manufacturers

Rx: Address Social Inequalities and Conditions that Fuel Violence

In a survey of 364 male and female inmates in Chicago who had been hospitalized at any time for violence-related injuries, fewer than half recalled anything said by their doctor or nurse. Of those, only one-quarter recalled any reassuring words, such as, “Do you have a safe place to stay?”, while others recalled negative comments, such as, “Stop complaining that it hurts!”

May JP. Addressing the gun violence epidemic. Presentation to the 18th National Conference of the National Commission on Correctional Health Care, San Diego. Sept 1994.

Rx: Jail and Prison

S: Reassure the patient that he is now SAFE and will be okay.

U: Be certain to UNDERSTAND the circumstances of the injury.

T: TEACH about the risks for violence-related injuries.

U: URGE nonviolent resolutions to conflict. R: Inquire about and discourage thoughts of violent

RETALIATION. E: Provide EMPATHY about the event, and

ENCOURAGE safer options.

SUTURE

Injury Surveillance• Intentional vs. unintentional

Documentation• Prior history on Problem List

Identification of High Risks• Example: prior incarceration, witnessing violence,

gang-related tattoo, prior STD, easy access to semiautomatic weapon

Counseling patients

Rx: Jail and Prison

COUNSELING PATIENTS ABOUT GUNS

COUNSELING PATIENTS ABOUT GUNS

COUNSELING PATIENTS ABOUT GUNS

COUNSELING PATIENTS ABOUT GUNS

COUNSELING PATIENTS ABOUT GUNS

School age children at homeSadness, depression, mental illnessSeen acts of violence

Talk to your patients about

guns and violence.

jmay@armorcorrectional.com

Questions?