Features
FEATURE
Issues related to gun violence and regulation are among the most divisive in the United States , with Americans split on the question of whether it is generally more important to protect the right to own guns ( 52 %) or to control gun ownership ( 46 %). 1 Physicians are no exception .
“ Many physicians and hematologists own guns , and not all doctors support gun control ,” Alan Lichtin , MD , a hematologist at Cleveland Clinic in Ohio , told ASH Clinical News . “ Doctors represent a wide spectrum of people , and some feel that any attempt to limit their access to guns or modify the second amendment is a great personal affront .”
For this reason , it should come as no surprise that , when the American College of Physicians ( ACP ) issued a call to action for policies to help mitigate the rate of firearm injuries and deaths , 2 the American Society of Hematology ’ s ( ASH ) decision to endorse the position paper did not come about easily .
The 2015 paper , published in the Annals of Internal Medicine and credited to eight health-care professional organizations and the American Bar Association , designated firearm-related deaths and injuries “ a major public health problem that requires diligent and persistent attention .” The authors called for a series of measures to help reduce the “ health and public health consequences of firearms ,” including universal background checks of gun buyers , restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use , and research to support strategies for reducing firearm-related injuries and deaths . 2 ( See FIGURE on page 115 for a list of the actions recommended in the ACP paper .)
Referencing the discussions the ASH Committee on Government Affairs held about endorsing the ACP ’ s paper , Alan G . Rosmarin , MD , chair of the committee , recalled the disagreement between members . “ In that small sample of people ,” he said , “ it was clear that not all hematologists were of one mind .”
ASH Clinical News spoke with Dr . Rosmarin and other members of the committee about the complexities of treating gun control as a health-care issue , and the role physicians can ( and cannot ) play in advocating for or counseling patients about firearm safety .
GUN VIOLENCE :
A Public Health Crisis
Does the oath to “ do no harm ” conflict with the right to bear arms ?
Firearms by the Numbers
Since the publication of the ACP paper , mass shooting incidents in the U . S . now include a nightclub in Orlando , Florida ( 49 fatalities ); a not-for-profit for people with developmental disabilities in San Bernardino , California ( 14 fatalities ); a church in Charleston , South Carolina ( 9 fatalities ); a military recruitment center in Chattanooga , Tennessee ( 5 fatalities ); a music festival in Las Vegas , Nevada ( 58 fatalities ); and a church in Sutherland Springs , Texas ( 26 fatalities ). 3
Mass shootings receive national attention , but the number of deaths and injuries resulting from these events is only a small percentage of the total firearm-related deaths and injuries anticipated each year in the U . S . In 2014 , the Centers for Disease Control and Prevention ( CDC ) estimated that there were 33,500 firearm-related deaths in the U . S . ( about 10.5 deaths per 100,000 population ), accounting for 16.8 percent of all injury-related deaths that year , and making firearms the third-leading cause of injury-related death . 4 For comparison , the National Cancer Institute ( NCI ) estimates that leukemia will result in 24,500 deaths in 2017 ( about 6.8 deaths per 100,000 population ), and lymphoma will result in 20,140 deaths ( about 5.9 deaths per 100,000 population ). 5 , 6
The two major causes of firearm death in the U . S . are suicide ( 63.7 %) and homicide ( 32.8 %), and firearms are estimated to injure an additional 67,000 people each year . The direct harm to victims is tragic , and the downstream consequences to the health-care system are grave . A review of emergency department ( ED ) visits for firearm-related injuries between 2006 and 2014 found that these injuries cost the U . S . health-care system approximately $ 2.8 billion in ED and $ 22 billion in inpatient charges annually . 7
“ There is a huge diversion of health dollars that are not going to logical places and are spent on something that is completely preventable ,” said Jerald Radich , MD , a medical oncologist with the Fred Hutchinson Cancer Research Center and professor at Washington University School of Medicine in Seattle . “ It hurts our patients and their families , who are all victims of this .”
How Does Gun Violence Affect Hematology ?
The question remains whether these statistics should be of specific concern to hematologists .
“ Gun-related injuries and deaths are roughly equivalent to the CDC estimate of the number of Americans living with sickle cell disease ( SCD ) – 100,000 – but [ the former ] are associated with a dramatically worse mortality rate ,” Jonathan G . Hoggatt , PhD , assistant professor of medicine at Harvard Medical School in Boston , Massachusetts , and a member of ASH ’ s Committee of Government Affairs , told ASH Clinical News . 8 “ A number of physicians go into work every day to help prevent injury and death , and [ firearms ] are a big source of that .”
Gun violence and injuries are also a drain on blood products – an already scarce resource in the U . S .
Patients with gun injuries require transfusions ; when mass shootings occur , that need multiplies . The transfusions required by patients with gun injuries “ take away from the national blood supply for people with hematologic disorders , such as SCD ,” Dr . Hoggatt said . In the two days after the mass shooting at the Route 91 Harvest musical festival in Las Vegas , for example , a nationwide platelet shortage restricted leukemia specialists from giving platelet transfusions to patients unless they were actively bleeding .
“ Guns are used to inflict injury on others , and those injuries often lead to a lot of bleeding ,” said Dr . Lichtin . “ So , is gun violence a concern for hematologists ? Yes .”
Other hematologists make the point , though , that gunsafety law advocacy may not be the best use of time and resources .
“ On the Committee on Government Affairs , we have tried to be mindful of the fact that we do not want to dilute the energy or attention from the patients and caregivers whom we advocate with and for ,” said Dr . Rosmarin , who is also professor of medicine at the University of Massachusetts Medical School in Worcester . “ We could list 100 topics we care strongly about , but maybe we should put our energies and dollars behind working on something that we have the ability to make a major impact on , like SCD .”
Loaded Questions
Despite the disagreement among medical professionals about whether gun control or counseling on firearm safety should fall under health care ’ s purview , there is broad agreement on one area : We need more research about the effects of firearm violence .
“ Physicians and scientists are a group of people who rely on evidence , but there are few strong studies about guns that can tell physicians what to do to improve patient safety ,” Dr . Hoggatt added .
According to Dr . Hoggatt , the U . S . has a long history of improving citizens ’ safety through policy actions . Three obvious examples include enacting food safety laws , reducing motor vehicle deaths by mandating the use of seatbelts and airbags , and restricting the use of tobacco in public spaces .
“ Physicians , scientists , and engineers – supported by government-funded agencies – were able to study better methods of food safety and rates of injury or death associated with motor vehicles or tobacco use , but they have been restricted in being able to study firearm injuries and deaths ,” Dr . Hoggatt said . “ The only unique thing about firearms compared with food or cigarettes is that they are protected by the Second Amendment .”
Many of the limitations on government-funded firearm research relate to what was dubbed “ the Dickey Amendment ,” a provision inserted as a rider into the 1996 federal government spending bill that mandates that “ none of the funds made available for injury prevention and control at the CDC may be used to advocate or promote gun control .” 9
This provision does not explicitly ban research on firearms , but Dr . Hoggatt explained , “ the CDC and other agencies have interpreted this very conservatively and fear for their funding . There is a feeling that if federal agencies start delving into the topic , and even
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