Written Testimony of Joseph V. Sakran, MD, MPH, MPA, FACS United States House Judiciary Committee February 6, 2019

2/6/2019
 

Chairman Nadler, Ranking Member Collins, and other members of the committee, thank you for the opportunity to be here today to share my experience, and perspectives on firearm- related injury and death in America. I am not testifying on behalf of Johns Hopkins University, but rather my role as a trauma surgeon at Johns Hopkins Hospital, a survivor of gun violence and a board member of the Brady Campaign.

Laying semi-conscious on the gurney, I could sense the frantic commotion of healthcare workers bustling around me in the trauma bay. Donned in protective equipment from head-to- toe, like a man on the moon, all I could see were the eyes of the trauma surgeon as he hovered over me. Those eyes reflected both intense concentration and fierce determination to save my life. They say a picture is worth a thousand words, but my memory of that face is worth a million.

Only hours before, I had been a healthy 17-year old student at a high school football game. One moment I was simply an innocent bystander and the next I became collateral damage as a violent fight broke out after the game and a 38-caliber bullet ripped through my throat, lodging in my shoulder. Nearly unconscious at the time, I still can vividly see the expressions on the faces of the many people trying to help me that day. The chaos around me in the trauma bay filled me both with fear and awe – fear that I might die and awe at the fearless purpose of the medical personnel fighting to save my life. A prolonged hospital stay, and many operations, gave me a second chance. This inspired me to become a trauma surgeon, and provide that same second chance for other people.

As a trauma surgeon, I and my colleagues are uniquely positioned to understand and address this issue. Every day, we are the ones that are on the frontline of caring for patients who suffer injuries from bullets. We are the ones trying to stop bleeding from pulverized tissue and torn flesh. We are the ones telling families that their loved ones are never coming home. We are the ones trying to deliver data-driven solutions with inadequate research funding. And we are the ones that understand all too often that the best medical treatment for this crisis is prevention.

For many years, the debate over how we prevent firearm-related injury and death was one that many members of my profession were reluctant to broach. That time has come to an end. Some have told us to stay out of the debate and “stay in our lane” – well, this is our lane, and doing nothing is not an option. And if we do nothing and maintain the status quo, 1 million Americans WILL be shot in the next decade.

Firearm injury and death in America is not only a disease,1 but a public health crisis in the United States. Every day, an average of 109 individuals are killed and more than 240 people suffer injuries secondary to firearm violence.2, 3 While the United States is a world leader in many arenas, we are failing when it comes to firearm injury prevention. Firearm-related injury and death is a public health problem creating a vast burden of disease across the spectrum of ages and socioeconomic groups in this country. Additionally, firearm-related violence has a substantial economic burden of over 229 billion dollars per year to the United States health care system.4, 5 Most concerning despite advances in trauma systems and health care capabilities, the fatality rate secondary to firearms has not significantly changed or improved.6, 7

In 2017, the Center for Disease Control and Prevention (CDC) reported 39,773 deaths from firearm injury. This accounts for 58% of all intentional injuries in the United States. Of these firearm-related deaths, 23,854 (60%) were suicides and 15,919 (40%) were homicides.2, 7 These numbers are the highest that have been seen in the past 20 years. Since 1999, there has been a 17% increase in firearm-related intentional injury mortality rates, with 7,000 more suicide deaths secondary to firearms in 2017 compared to 1999.2, 8

The mass shootings that we have become all too familiar capture less than 2% of the entire epidemic we face as a nation. Every day in cities like Baltimore, Philadelphia, and Chicago we have young black men that are killed, and their stories often go untold. Despite the small proportion of the overall epidemic mass shootings are responsible for, in the United States mass shootings have been increasing in frequency since at least 2011. While the term “mass shooting” has different definitions among organizations, we define it as any firearm-related incident resulting in injury or death of 4 or more people. Semiautomatic weapons are commonly used in active shooter incidents resulting in more people being injured or killed.9

Recognizing we have a problem is essential, and this is a multi-faceted health problem requiring a diverse group of stakeholders including but not limited to healthcare professionals and organizations, public health leaders, survivors, manufacturers, academia, gun owners, and yes young people. We must develop a broad multidisciplinary, multi strategy systems approach that is supported by good science and research.

We have best practices that we can learn from. Look at motor vehicle crashes in the latter half of the 20th century, we initially focused on the drivers. We then broadened our approach from, “who caused the crash” to, “factors that lead to death or injury”. We determined that numerous fatalities were caused by crashing into trees, heads smashing into steering wheels, or being ejected from vehicles. We invested in research. We developed solutions like seat belts, air bags, and safer roads. Since then we have seen fatalities per mile driven fall by 85%. This is the essence of the public health approach: multisector, research informed, evidence-based programs and policies. In response, we developed safer cars and roads, and we saved lives.

The American College of Surgeons Firearm Strategy Team (FAST) work group, a group composed of surgeon leaders that are firearm owners, recently published a consensus statement10 describing firearm injury prevention solutions that is consistent with the public health approach. This is yet another demonstration that as Americans, we have much more in common than we have than that which divides us. The false narrative that exists throughout social media and other outlets attempts to polarize a discussion at a time when now more than ever we must be united. It is thought that the vastly different viewpoints that may exist around firearms have brought our nation to a standstill and prevented improvement in violence and injury prevention.

In 2015, a public opinion survey from the Johns Hopkins Center for Gun Policy and Research was conducted among gun-owners and non-owners. Both 84% of gun-owners and 84% of non- owners favored background checks for all gun sales. Additionally, 78% of gun-owners and 80% of non-owners favored preventing sales to people with temporary domestic violence restraining orders. The majority of both owners and non-owners also supported the release of data on which gun dealers sell the most guns used in crimes, requiring a license before buying a gun to verify identify, and temporarily removing guns from individuals who pose immediate threat of harm to self or others.11

A few weeks ago, Congressman Mike Thompson and Peter King introduced the Bipartisan Background Check Expansion Act (HR 8) on the anniversary of Congresswoman Gabby Giffords near fatal injury. The Brady Handgun Violence Prevention Act, or “The Brady Bill,” was signed into law in 1993 by President Clinton and instituted background checks at federally licensed gun dealerships designed to prevent high-risk individuals from purchasing firearms. This bill instituted the FBI to run each firearm purchaser through the National Instant Criminal Background Check System. Prohibited users include felons, fugitives, domestic abusers, and dangerously mentally ill individuals. Since the success of the Brady Bill and Brady Campaign, over 3 million attempts to purchase firearms have been prevented; about half of these blocked attempts were attempted purchases by felons.12

Background checks are a strongly evidence-based method to reduce firearm violence.2 In addition, this process is critical to ensuring appropriate individuals have access to obtaining firearms, and avoiding sales or transfer of firearms to criminals or others who should not have access to these weapons.

While the Brady Bill has been successful in limiting gun sales in federally licensed gun dealerships, a significant proportion of firearms are sold through non-licensed dealers that are not mandated to perform background checks.13,14 Currently, background checks are not required for guns sold at gun shows, online, or through private transfers. In total, these sales account for an estimated 6.6 million firearms.14,15 Another way to think about it is 1 in 5 (20%) gun sales take place with “no questions asked” resulting in thousands of guns going into the hands of people that shouldn’t have them.

We must also ensure federal investment for firearm injury prevention research, implementation of Extreme Risk Protections Orders, education on safe storage, firearm safety technology investment, expanded access to behavioral health services, and improving victim services that begin in the hospital, and expanding victim rights to bring recourse in the courts against gun manufacturers for their negligent acts.

In 1996, Congress passed the Dickey Amendment in the omnibus spending bill mandating that none of the funds made available for injury prevention and control at the CDC could be used to “advocate or promote gun control.”16 In addition, in that same spending bill Congress stripped the CDC of 2.6 Million dollars, which happened to be the exact amount allocated in the prior year to firearm research. These actions severely limited research funding dedicated to firearm- related violence over the past two decades.17 In 2011, this was extended to include all federal agencies including the NIH.18 More recently, in 2013, President Obama signed an Executive Order permitting the CDC to study or sponsor research dedicated to firearm injury prevention.19 While this Executive Order created opportunities for funding injury prevention secondary to firearm-related injury and death, Congress has failed to appropriate the necessary funds to allow for research in this arena.

This funding limitation has substantially impacted firearm-related violence research. Violent injury secondary to firearms is the most poorly addressed public health problem in the US and is drastically underfunded given its substantial burden of disease.8 One study compared the mortality and research funding of different disease states. The number of deaths from firearm violence and sepsis were nearly the same in 2014. However, when comparing funding, the aid dedicated to gun violence research was 0.7% that of sepsis and the publication volume was only 4%.20 Of all diseases compared in this study, firearm violence was the least researched cause of death.20

We have both the opportunity and responsibility to comprehensively address gun violence as the true public health crisis that it is. This is not a Democrat versus Republican issue. It’s a uniquely American issue and it is uniquely in each of your hands to help fix it.

The America I’m fighting for is one where parents no longer have to fear the phone call that my parents received, that the Parkland parents received, and literally hundreds of others in communities across this country are receiving every single day. As a trauma surgeon, I have to look into the eyes of these parents and it’s nothing less than heartbreaking. The medical community implores you: the time for action is now. There is no one solution to this complex health problem, which is why we must come together as a country to build consensus and support and develop a research informed, data-driven, approach so that we can help you, as our policy-makers, to ensure the public safety of Americans all across this great nation.

References

  1. Hargarten S, Lerner EB, Gorelick, M, et al. Gun Violence: A Biopsychosocial Disease. West J Emerg Med. 2018;19(6):1-4.
  2. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death. 1999-2017 on CDC WONDER Online Database, released December, 2018. Data are from the Multiple Cause of Death Files, 1999-2017, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Available at: http://wonder.cdc.gov/ucd-icd10.html.
  3. Gani F, Sakran JV, Canner JK. Emergency Department visits for firearm-related injuries in the United States, 2006-14. Journal of Health Affairs. 2017; 36(10):1729-1738.
  4. Tasigiorgos S, Economopoulos KP, Winfield R, et al. Firearm injury in the United States: An overview of an evolving public health problem. J Amer Coll Surgeons. 2015; 221(6):1005-1014.
  5. Follman M, Lurie J, Lee J, et al. The true cost of gun violence in America (2015) http://www.motherjones.com/politics/2015/04/true-cost-of-gun-violence-in-america.
  1. Cook PJ, Ludwig J. Guns in America: National Survey on private ownership and use of firearms. Washington, DC: US Department of Justice, National Institute of Justice Research in Brief; May 1997. www.ncjrs.gov/pdffiles/165476.pdf.
  2. Wintemute GJ, Braga AA, Kennedy DM. Private-party gun sales, regulation, and public safety. NEJM. 2010; 363(6):508-11.
  3. Kellerman AL, Rivara FP. Silencing the science on gun research. JAMA. 2013; 309(6):549-550.
  4. He K, Sakran JV. Elimination of the moratorium on gun research is not enough. The need for the CDC to set a budgetary agenda. JAMA Surg. 2018; doi:10.1001/jamasurg.2018.4211.
  5. Consolidated Appropriations act 2023; PubLNo.112-74. http://www.gpo.gov/fdsys/pkg/PLAW-112pub174/pdf/PLAW-112pub174.pdf. December 2011.
  6. Presidential Memorandum – Engaging in public health research on the causes and prevention of gun violence. January 16th, 2013. https://www.whitehouse.gov/the... DE, Shah NH. Funding and publication of research on gun biolence and other leading causes of death. JAMA. 2017; 317(1):84-86.