COMMENTARY
Gun Violence: A Biopsychosocial Dia
Stephen W. Hargarten, MD, MPH*¶E. Brooke Lerner, PhD*¶
Marc Gorelick, MD, MSCE †Karen Bral, MD, MPH ‡
时空穿越
Terri deRoon-Cassini, PhD §Sara Kohlbeck, MPH ¶
Section Editor: Jeremy Hess, MD, MPH
Submission history: Submitted February 21, 2018; Revision received May 30, 2018; Accepted July 18, 2018 Electronically published September 10, 2018 Full text available through open access at /uc/uciem_westjem DOI: 10.5811/westjem.2018.7.38021
Medical College of Wisconsin, Department of Emergency Medicine, Milwaukee, Wisconsin Children’s Hospital and Clinics of Minnesota, Minneapolis, Minnesota Oregon Health and Science University, Department of Surgery, Portland, Oregon Medical College of Wisconsin, Department of Surgery, Milwaukee, Wisconsin Medical College of Wisconsin, Comprehensive Injury Center, Milwaukee, Wisconsin
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Gun violence is a pervasive public health burden in the United States. Annually, over 36,000 Americans die from firearm-related events; tens of thousands are injured.1 The medical community has periodically called for framing gun violence as a public health/medical issue.2-9 Given the impac
t of gun violence on health and longevity,10 others have suggested that physicians have a moral obligation to address gun violence.11,12 More recently, others have called upon physicians to integrate firearm-related education about safety with their patients.13
Calls for engagement have incread with multiple physician organizations calling for action.2,14 In much the same way that human immunodeficiency virus (HIV) rates grew unchecked until we began to acknowledge that it was a biopsychosocial dia that could be prevented and controlled, and scientifically we moved past the social stigmas of a dia first recognized as largely affecting
homoxual men, gun violence will continue unchecked until we invest in rearch to discover effective means to reduce it. To fully engage physicians and other ctors of the healthcare community, we need to frame gun violence as a biopsychosocial dia.12 We know that gun violence follows predictable patterns just like infectious
dias and other illness.15 For example, young African-American males are at incread risk of firearm-related homicide, while older White males are at incread risk for firearm-related suicide. Through an understanding of the risk factors for a dia, we can identify means of control and prevention.校长不要
The dia model approach was first advanced in the 19th century and continues today. With a science driven understanding of dia etiology, physicians and other civic leaders were positioned to discover vaccines, thus changing the environments that breed the vectors of illness, while identifying high-risk groups for preventative interventions– all driven by the science of discovery. We are eing this unfold today with the Zika virus,16 and the prevention strategies of other communicable dias such as tuberculosis and HIV that continue to benefit from the rigorous application of the dia model. By identifying and understanding the dia agent, its vector of transmission, and the high-risk hosts and environments, all ctors of civil
Hargarten et al. Gun Violence: A Biopsychosocial Dia
society – healthcare, public health, business, schools,
fire and police agencies– can work in concert to institute interventions that reduce morbidity and mortality. The interventions may prevent exposure to the agent that caus dia, reduce the chance of becoming ill if expod, or limit the damage after the dia is contracted.
Scientific investigations have advanced the dia model to include other caus of cellular/organ damage from a variety of etiologic agents.17 For decades, clinicians and public health professionals
have been trained to understand the definition of dia as having four components: etiology, pathogenesis, morphologic changes, and clinical significance.17 We have learned that the etiologic agents of dias are categorized into biologic and physical agents that interact with cells and organs, resulting in disruptions of cell walls and the relea of substances that cau additional destruction.18 For example, with the Ebola virus dia, the pathogenesis occurs over days and can manifest up to 21 days after exposure. The virus begins to replicate and results in morphologic changes in cells/organs that manifest as a constellation of symptoms, resulting in naua, vomiting, and diarrhea, leading to dehydration, organ failure and death.
Analogously, the kinetic energy from a bullet is
the physical agent of gun violence. The kinetic energy imparted by the speeding mass of the bullet results in the tearing of cellular membranes, leading to edema, fractures, and bleeding, resulting in organ failure, shock, and death. The energy (KE=1/2MV2), is transmitted to
the host/patient from the bullet – penetrating the skin, entering the body, and transmitting the energy, leading
to temporary and permanent cavity formation, and a
sterile injury to the patient.18,19 The pathophysiology of
this dia has received limited examination becau the agent (kinetic energy) caus destruction so quickly (less than 0.1 c).20 The high-speed video camera is the “microscope” for this rapidly occurring dia. It
is through this “lens” that we can document the temporary and permanent cavity formation that is the hallmark of
the biology of this dia.19-21 This dramatically brief pathophysiology limits acute interventions during the relea of kinetic energy and is distinctive since dias from other agents, such as virus and bacteria, clinically develop over days or weeks.
By framing gun violence as a biopsychosocial dia,22 it engages the healthcare community of physicians and nurs, complements the necessary multidisciplinary approach to advance our scientific understanding, and informs host, agent/ vector, and environmentally-focud interventions beyond the immediate biology of fractures, bleeding, and edema. This
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is critically important since preventing and controlling gun violence will not occur to any significant de
gree until we begin to approach it in a manner similar to controlling other biopsychosocial dias such as HIV. One immediate benefit of framing gun violence as a dia is the opportunity to address misleading/limiting statements as scientifically inaccurate, yet repeated over and over again. One of the most common of the is: “Guns don’t kill people, people kill people.”法务工作内容
The dia model provides us with accuracy: the bullet and its kinetic energy shreds, tears and destroys cells, and damages organs, leading to death and disability. While the behavioral health issues that result in a person pulling a trigger and releasing the energy need to be better understood, first and foremost we need scientifically accurate statements that advance the necessary, challenging discussions. By recognizing that bullets kill people, the gun, which carries the bullets, becomes a necessary focus of intervention. One such strategy would be to limit the rate of the relea of bullets by, for example, banning bump stocks or automatic weapons, or by reducing the amount of potential energy the gun can carry (magazine capacity). Without this framing we will be limited to education of our patients13 or continue to be stuck, mired in debates that do not advance scientific understanding, but only entrench positions. We limit progress related to gun violence by not addressing the environment and the social context and psychological antecedents and outcomes of this dia that affect patients, families and communities.23,24
In addition to the injury caud by a bullet, the body’s own biologic stress respon is activated and involves a cascade of bodily systems, including stress hormones. While this biological respon is adaptive, sustained activation of the acute stress respon degrades healthy adaptation following a life-threatening situation. This is even further exacerbated when an individual experiences psychological stress after trauma, particularly post-traumatic stress disorder (PTSD). The social context of gunshot-wound patients is paramount, including the community/neighborhood the survivor is coming from, the location of the wounding event, and the environment to which they have no choice but to return. Unfortunately, issues such as familial retaliation and the maintenance of perceived strength within communities with high levels of violence can perpetuate the cycle of gun violence, “spreading” the risk of the dia. Social, environmental, physical, and psychological pre-, peri-, and post-injury factors influence the cour of gun violence as a dia and therefore should be treated from this biopsychosocial perspective.
There are many opportunities for medical communities to treat gun violence as a biopsychosocial dia. Increasingly, trauma centers25 are recruiting clinical psychologists to provide behavioral health interventions that complement the surgical team’s emphasis on the biology. While the integration of behavioral health specialists is occurring within centers where the dia is most likely to be treated, the majority
of centers are not yet advancing care with this integrated approach. Behavioral/social interventions include hospital-bad, violence-prevention programs, where the focus is to
Gun Violence: A Biopsychosocial Dia Hargarten et al.
address the social and behavioral issues of gun violence and to prevent recidivism. In some instances, primary care physicians are26 trained in asssing exposure to trauma to understand the social context of the patient’s health. They can provide recommendations for psychological care if distress is evident. While the examples exist within healthcare, unfortunately they are not the norm. To move dia prevention forward, significant development of integrated multidisciplinary programs is needed. Additionally, more rearch is needed in the inpatient tting of trauma centers to better understand the psychosocial elements of this dia to maximize outcomes and reduce recidivism.
The importance of this framing distinction can be more easily en when we consider prior and ongoing work to reduce the burden of acute injury from car crashes. We have achieved considerable success in the application of the dia model, which has resulted in significant reductions in death and disability over the past 50 years.
Evidence-bad policies such as atbelt laws and significantly improved car and road designs that attenuate and control the energy exchange with pasngers and drivers – all components of the dia model – have been systematically investigated and advanced.29
In the first 10 years of the 21st century there were substantial declines in morbidity and mortality from other public health burdens such as vaccine-preventable dias, childhood lead poisoning, cardiovascular dia, workplace-associated injuries, and cancer, while improvements were made in areas such as maternal and fetal health.27 However, similar improvements have not been made in firearm deaths during this time; in fact, deaths from firearms continue to ri. This may be attributed, at least in part, to the relative paucity of funding for firearm-violence rearch, due in part to the 1996 Dickey amendment, which states that, “None of the funds made available for injury prevention and control at the Centers for Dia Control and Prevention may be ud to advocate or promote gun control.”28
As a society, we have achieved success in controlling infectious dias with a focud, dia-model approach, and we have successfully expanded the u of the dia model to prevent and control non-communicable dias such as cancer and heart dia. We have ud this approach for other challenging biopsychosocial dia burdens such as smoking and alcohol abu.30 Furth
er, it was only once
we blunted the political stigma stunting our progress in combating HIV that the most significant discoveries took place and lives were saved. Yet we have not taken the next step in using the dia model to prevent and control
gun violence, in part due to the relative lack of funding,
and therefore the relative lack of investigation. Framing
gun violence as a dia places it firmly
within medical and public health practice. Interventions across multiple ctors, informed by comprehensive, linked data and rigorous, adequately-funded rearch, can be ud to prevent injuries, improve acute care and rehabilitation, and inform and evaluate program and policy interventions. The can ultimately reduce morbidity and mortality.
This framing opens up important areas of rearch and prevention strategies that can and must be organized to address all aspects of the dia: high-risk youth; adults and elderly; the gun and the bullets; and the environment.30 Specific examination of the gun and its design/safety characteristics
open up areas of potential interventions. Much like reducing a child’s access to the energy contained in a medicine container resulted in decreas in unintentional chemical injury from aspirin and Tylenol,31 banning bump stocks would reduce the rate of energy relea that was so tragically en in the Las Vegas shooting of October 2017. Designing a “smart” gun, which leverages new technologies to identify a gun’s owner and prevent its u by others, could also have the potential to reduce the number of accidental (unintentional) deaths and suicides.33, 34 In this environment, requiring background checks on all gun sales has the potential to further reduce unauthorized access.35
Recent calls to engage the physician and public
health communities in addressing gun violence6,11,36 must be answered by the medical community. Kair Permanente, one of largest health systems in the U.S., has recently approved a $2 million expenditure to study gun violence prevention.37 By framing gun violence as a biopsychosocial dia we can move beyond acrimony and fear, u the tools that have been honed over centuries to advance science, and prevent and control this dia burden that adverly impacts our patients, families, and communities across the U.S. and the world. ACKNOWLEDGMENTS
The authors wish to express their gratitude for manuscript preparation to Dawn Lyons.
Address for Correspondence: Sara Kohlbeck, MPH, Medical College of Wisconsin, Comprehensive Injury Center, 8701 W. Watertown Plank Rd., Milwaukee, WI 53226. Email: skohlbeck@ mcw.edu.
Conflicts of Interest: By the West JEM article submission agreement, all authors are required to disclo all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.
Copyright: © 2018 Hargarten et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) Licen. See: / licens/by/4.0/
Hargarten et al. Gun Violence: A Biopsychosocial Dia
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