The vacuum in gun violence research in America is slowly being filled by independent organizations. The latest to accept the responsibility for studying one of our most pressing public health crises is Kaiser Permanente, the giant healthcare system, which this week announced a $2-million program to study how to prevent gun injuries and deaths.
With more than 12 million members and a presence in communities with 65 million residents, says Bechara Choucair, the organization's chief community health officer, "we feel a responsibility to address public health issues, and gun violence is one of those issues."
Firearm-related injuries caused 30,000 deaths in 2016, the latest year for which statistics are available. Kaiser
Permanente physicians treated 11,000 gunshot injuries in 2016 and 2017 combined.
"Whether firearm-related injuries and deaths are coming from suicides, homicides or accidents," Choucair told me, "we feel we're particularly well-positioned to understand what role healthcare systems can play to help prevent them."
Kaiser Permanente's effort appears to be unique among nonacademic medical institutions. But it may be uniquely situated to perform the sort of clinical studies that have been sorely lacking in U.S. gun violence research. The system is known for its ability to conduct clinical research among its huge patient base, including research into cardiac and cancer treatment.
In turning its sights on firearms violence, Kaiser Permanente will be helping to fill a gap created by federal agencies' fears of the National Rifle Assn. In 1996, the NRA strong-armed Congress into eliminating the $2.6 million it had appropriated for gun violence research by the Centers for Disease Control and Prevention. Congress then passed a measure drafted by then-Rep. Jay Dickey (R-Ark.) forbidding the CDC to spend funds "to advocate or promote gun control." (Dickey later would publicly regret his amendment.)
The Dickey Amendment didn't technically ban any federally funded gun violence research. The real blow was delivered by a succession of pusillanimous CDC directors, who decided that the safest course bureaucratically was simply to zero out the whole field. The result was to reduce gun violence research to an uncharted desert.
Non-federal institutions have recently moved to fill in the blanks. One is UC Davis, which has established the Firearm Violence Research Center with a five-year, $5-million grant.
The center's director, Garen Wintemute, welcomes Kaiser Permanente's initiative. "In this field, a $2 million research commitment will make a difference," he told me by email. "One possibility that I find particularly exciting: Kaiser would be an ideal setting for research on how best to integrate firearm violence prevention into patient care."
The $2 million may be just a start — a "down payment," says David Grossman, a physician and expert in gun injury prevention at Kaiser Permanente in Washington state who will be co-leader, with Choucair, of the system's task force on firearm injury prevention. Physicians know how to treat firearm injuries when they present at the hospital and have a good idea of which groups are most at risk. Therefore, Grossman said, the research will focus on interventions that physicians can perform for patients in high-risk groups, such as those vulnerable to abuse by intimate partners where "there is a firearm in the picture."
"As clinicians, we're seeing those folks," Grossman told me. "We have an opportunity to help and intervene, and we'd like to know how we can be most effective."
Grossman already has some experience in learning how intervention can reduce injury and death. In 2011, before joining Kaiser Permanente, he studied what happened after gun safes were installed in rural native Alaskan households, 95% of which owned guns. The study found that the ratio of homes with unlocked guns fell from 93% to 35% in a year, a trend the study team conjectured would lead to reduced gun-related injuries and deaths in the community.
The system's doctors also have experience intervening to address chronic conditions such as alcoholism or motor vehicle injuries. "As a family physician, I've counseled thousands of patients over the years how to quit smoking or prevent car accidents," Choucair says.
"There are decades' worth of research that tell us how to screen for these issues, who to screen for these issues, what type of questions to ask, and if somebody screens positive, what are the types of interventions you need to do to address these issues. The reality is that when it comes to firearm injuries, we don't have that body of research. We're hoping that $2 million will start to fill in the gaps."
One other difference: the political component. Few areas of American life are as touchy as gun ownership. It's not unheard of for gun-happy state legislators to try to limit doctors' abilities even to ask patients about guns in the home, an example of how politics can infiltrate the clinical office. (One such gag rule enacted in Florida was invalidated last year by a federal appeals court.)
The system's initiative will step lightly around politics, Choucair says. "It's really, really important that we are leaving the policy debates to policymakers," he says. "This is truly about science; this is not about politics. This is a journey to help us fill in very specific gaps regarding what works in the clinical space and our communities to prevent firearm injuries."