Public Health

Q&A: How public health approach to gun violence is breaking barriers

Andis Robeznieks , Senior News Writer

Imagine 109 Americans dying each day from a known cause, but the federal government refusing to spend any money on research to try to better understand it. 

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Yet, that had effectively been the status of firearm violence-prevention research since 1996, when an amendment was added to an omnibus federal spending bill to bar Centers for Disease Control and Prevention (CDC) research funds to be used in promoting or advocating gun control. 

The so-called Dickey Amendment kept a lid on any CDC funded research that might have helped reduce a problem that causes almost 40,000 deaths in the U.S. each year—including almost 24,000 suicide deaths. 

Even after the 2012 mass shooting at Sandy Hook Elementary School, the Dickey Amendment remained in effect. As it did until March 2018. That was when another omnibus spending bill contained a clarification stipulating that the 1996 provision did not prohibit federal funding of research into the causes of firearm injury and death. 

Physicians had been in the forefront calling for this change and for the nation’s plague of firearm injury to be tackled as a public health issue. 

The AMA views gun violence as a public health crisis and advocates that restrictions on federal funding for firearms violence research be removed. The AMA supports federal and state research on firearm-related injuries and deaths and increased funding for and the use of state and national firearms-injury databases to inform state and federal health policy. 

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Megan L. Ranney, MD, MPH, an emergency physician at Brown University in Providence, Rhode Island, and co-founder and chief research officer at the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), has been a leader in this movement. (The AMA is partnering with AFFIRM in its effort to restart the science of firearm-injury prevention.) 

Megan L. Ranney, MD, MPH
Megan L. Ranney, MD, MPH

When the CDC recently announced that it was releasing more than $7.8 million to be spent on 16 grants funding research into preventing firearm-related violence and injuries, Dr. Ranney’s name was on one of the awards. 

Dr. Ranney, a group of co-investigators across the country, and her partners at AFFIRM Research received a first-year grant of $650,000 to evaluate the effectiveness of “bystander interventions” among youths participating in 50 4-H Shooting Sports clubs. 

Dr. Ranney recently spoke with the AMA about her journey as an activist, physician-scientist, the significance of her CDC grant, and AFFIRM Research’s approach to preventing firearm violence. 

AMA: How many years in the making was your recent CDC grant award and how did it feel to be among the grant recipients? 

Dr. Ranney: I’ve been trying to encourage increased federal funds for firearm injury-prevention research for almost a decade now. 

When I first started as a fellow in injury-prevention research, I was really interested in doing working on how to prevent gun violence and I was told pretty explicitly at the time that I couldn’t do research on gun violence because it was a “career killer,” and that there was no funding available. 

I took that as gospel because I was told that by very senior people in the field. But after I got a few years into my faculty position [then assistant, now associate, professor with Brown University’s Warren Alpert Medical School], I started to realize that it didn’t have to be true—and, just because someone told me that it currently wasn’t funded doesn’t mean it couldn’t be funded ever. 

Around the same time, Sandy Hook happened, which was a big wake-up call for many of us across the United States. Starting around that time, I and others started work to redefine firearm injuries as a public health problem rather than a criminal justice problem, and to talk openly in public forums about the fact that one could approach firearm injury from a nonpartisan perspective. 

The CDC had had funding removed from it because of a perception that doing firearm injury-prevention research was the same thing as gun control and this is what I—along with Emmy Betz, MD, and Garen Wintemute —started to talk about: This doesn’t have anything to do with “gun control”. This was about preventing firearm injury the same we do for any other kind of injury—from drowning to car crashes. 

There were many days early on that that work felt hopeless. But, little by little, we started to get people on board.  

The AMA was one of the early, large organizations that Dr. Betz and I spoke to, along with the American College of Emergency Physicians and others, who came onboard and became fellow advocates for changing the way our country approached the firearm-injury epidemic. 

Then it was really after the #ThisIsOurLane movement a few years ago, which I was one of the leaders on—along with my organization, AFFIRM Research—that we started to see an uptick in Congress’ willingness to fund this research. 

Then last September, the appropriations came through and I put in my grant application in May knowing that I was going to be considered in a perfectly unbiased, blinded, peer-reviewed manner by a grant review committee.  

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I got the notification of the award in September. It’s just so exciting. This specific research study is really the culmination of years of work—not just ... to try and get funding for everyone—but also the years of work I’ve done specifically with AFFIRM Research to develop community-based approaches to firearm-injury prevention. 

AMA: Tell our physician readers more about the research project the CDC is funding. 

Dr. Ranney: We’ve developed this model that we call a “Reframe,” where we use narrative to move communities from stories of tragedy to stories of hope and to incorporate evidence-based interventions that people in a community can use to identify who’s at risk and to minimize risk for those people. 

So, with this specific grant, we’re going to adapt the Reframe approach to use with 4-H youth Shooting Sports Clubs. Knowing that many of these kids are entering, or are already part of, a gun-owning culture or family of firearm owners, it is essential to engage them in these early formative years. 4-H already teaches them how to handle guns safely, themselves. We hope to teach them how to identify risk among their friends or family members—and, potentially, themselves—and, then, to know what to do when they’re worried that a friend or family member may be at risk of gun suicide, gun-related domestic violence or at risk of a school shooting. There are strategies that can be used to reduce that risk, and our hope is to impart those with the kids. 

It’s a super exciting project. It’s going to be in 50 4-H shooting club communities across the United States in partnership with AFFIRM and 4-H.  

When we were putting this together, it felt like: “This is too ambitious; it’s never going to fly.” Then we got the funding notice and it’s so exciting for all of us to have this opportunity to do this work, validate it, and to disseminate it. ... 

My co-founder with AFFIRM, Christopher Barsotti [MD], is a firearm-owner himself. He is also a 4-H rifle-safety instructor and an emergency physician. He’s really a key driver of this idea. It’s a partnership. 

AMA: Would you tell us more about the significance of storytelling in your work? 

Dr. Ranney: Though I’m a scientist, I’m also a physician. As physicians, we all know the importance of personal connection and the power of storytelling—both in listening to patients’ stories and, sometimes, sharing our own.  

I think that the power of storytelling really hit home for me during #ThisIsOurLane. During that moment, it was physicians and other healthcare workers sharing our stories about our personal experiences with gun injury and death—whether those stories were clinical or about families and communities. 

That was what really resonated with general America. And that helped to drive the change that led to this CDC funding. It allows people to relate to, empathize with, and connect to a problem in a way that is difficult to do reproduce in other ways. It is an essential part of AFFIRM’s Reframe methodology. The whole Reframe model is based on the idea of storytelling and narrative. We’ve learned a lot over the years. 

AMA: Please explain the difference between the grants AFFIRM awards and the one you received from the CDC. 

Dr. Ranney: The AFFIRM awards are small, single-year grants for people who are just getting started and are interested in generating pilot data and validation of an idea. The CDC grants are much larger, cover multiple years and are for studies designed to provide definitive evidence.  

But the small grants are important because the field has largely been frozen for 20 years. There is so much to do, and so few people have any pilot data. The analogy is like what if we haven’t done any research on heart disease since 1996? That would be ridiculous, but in the field of firearm injury we’re trying to make up for 20 years of virtually no research. 

AMA: In your TED Talk, you tell the story of not being able to save a boy who had shot himself with his father’s gun. To what degree is the public health issue of gun violence connected to the problem of suicide, now the 10th-leading cause of death in the U.S.? 

Dr. Ranney: I would describe them as deeply interlinked. The drivers of firearm suicide are so similar to the drivers of firearm homicide and firearm domestic violence. If we can reduce one, we are likely to reduce them all. 

There is no one, single method or strategy that is going to reduce any one of those types of firearm injury, but they have many of the same underlying drivers: Feelings of hopelessness, impulsivity, easy access to firearms in a moment of despair or fear.  

That’s part of the reason our [CDC research] bystander intervention program is going to teach youth how to approach all those risk factors. At the end of the day, it comes down to putting space and time in between someone who is at risk and their access to a firearm.  

Firearm owners are, by and large, tremendously safe and at low risk of injuring themselves or their family. But every once in a while, a risk will pop up and that requires the owner and the community to identify the risk and to know what they can do. 

AMA: How do you recommend that physicians talk about firearms with patients

Dr. Ranney: The first thing is to come at it from a perspective of harm reduction and also a recognition that firearm ownership is a big part of our American culture. Approximately 30% of Americans own firearms. If we diminish firearm ownership as “stupid”, that would be ignorant of our country’s history as well as disrespectful of our colleagues and communities. 

The was that I deal with it is the same way I talk about other behavioral choices that we make. I drive cars and that puts me at risk for a car crash, but I’m smart about not driving after I drink, always wearing a seatbelt, slowing down at a railroad crossing, and making sure my kids are in car seats. If we can take that approach to firearm injury—where we see it as minimizing the risk from a tool, rather than a stigmatization of a behavior, we have a much greater chance of actually making progress. 

AMA: Thank you for your time, and congratulations again on the grant. 

Dr. Ranney: Lastly, I want to say “thank you” to the American Medical Association for its longtime partnership with AFFIRM Research. This would not have happened without medical societies coming together to assert the importance of this public health approach. 

You have been leaders for years in making this happen. I’m thrilled to take it to the next level, and I hope we’ll finally have some data to back up our hypothesis.