An ER Doctor’s ‘Third Way’ Approach to the Gun Crisis

Nearly 15 years ago, a young man who had shot himself in the head with his father’s gun was wheeled into the emergency room where Megan Ranney worked. Despite her team’s best efforts, the patient died. “It was the first firearm suicide I’d ever taken care of,” Ranney, an emergency physician and public-health expert in Rhode Island, told me. In the days after, Ranney found herself wondering about the circumstances that had landed that boy in her hospital. What had made that gun so easily accessible? Why had he reached for it? What had failed to stay his hand?

In the decade-plus since, many, many more firearm injuries have crossed her path—“truly, I can’t even count the number of folks I’ve taken care of who have been shot,” she said. Each year, guns kill tens of thousands of people in the United States; on Tuesday, an 18-year-old gunman added at least 21 more to 2022’s horrific tally, when he entered an elementary school in Uvalde, Texas, and opened fire in a fourth-grade classroom. Like other mass shootings, this one has turned the national conversation toward laws that could cut down on firearm-related deaths (of which mass shootings make up just a small fraction). And it’s true: Policy change could make a difference. But if history tells us anything, chasing after legislation will not reduce gun deaths on its own. Firearm injuries, Ranney said, are also a public-health crisis that demands public-health solutions—ones that can be enacted not just by the nation’s leaders in the future, but by individuals and communities right now.

America has, of course, been squaring off with a very different sort of epidemic over the past two and a half years. COVID has showcased the power of public-health initiatives. It has also forced us to acknowledge what happens when those same efforts falter. Outbreaks of infectious disease are complex: They are about pathogens, yes, but also about the people who ferry them from place to place, the tools we use to hamper their spread, and the preventive behaviors communities are and are not willing to take. They spread fast and disproportionately affect certain people, but they can be stopped before they spiral out of control. In much the same way, “there is a long pathway that gets people to the point where they pick up a gun with the intention to hurt themselves or another,” said Ranney, who five years ago co-founded AFFIRM at the Aspen Institute, an initiative taking a health-based approach to ending the American firearm-injury epidemic.

I called Ranney to talk with her about the public-health approach to reducing firearm injury. Our conversation has been edited for clarity and length.

Katherine J. Wu: Explain why firearm injury is a public-health problem, and not just a policy one.

Megan Ranney: People continue to harden into these two extreme positions: Get rid of all guns, or give everybody a gun. Gun rights versus gun control. When there’s a shooting, the two sides get louder and louder, and further and further apart. The way that we have been approaching this is clearly not working.

But there is a third way, which is addressing this as a health problem, which this very much is. It brings people into my ER day after day. Core to public health is the idea that you have to think on a larger scale—not just about the patient in front of you, but also about individual- and population-level risk factors, and how to modify and reduce them. Some of that might be about the firearm and policy related, but some are also going to be about the person, and some are going to be about the neighborhood or the structure.

We talk about car crashes as a health problem; we’ve set up whole systems to reduce car-crash injury and death. We talk about heart attacks as a health problem, and we’ve set up whole systems to reduce the incidence and severity of heart attacks. Why are we not doing the same thing for guns? And I want to be specific that I’m talking about firearm injury, not about the firearms themselves. For motor-vehicle crashes, the car is that mechanism, but our goal is to reduce the crash, and the death on the other side.

Wu: What does a public-health approach offer us? Is there another instance in which policy solutions have faltered, or become stagnant, and public health was able to successfully step in?

Ranney: Car crashes are the example that I most frequently bring up. By some metrics, we’ve decreased the number of car-crash deaths by about 70 percent since the 1970s—not by banning cars, but rather by making cars safer, by making drivers safer, and by developing car seats and teaching parents how to use them. There’s a combination of education, engineering, and policy that has been put in place to decrease car-crash deaths. Another example is HIV. We’ve used science and the public-health approach to identify what causes HIV and help reduce its transmission, as well as its likelihood of causing death. Yes, it’s about basic research and antiretrovirals. But it’s also about a harm-reduction approach around safer sex, safe syringe-needle use, safe injection sites, and giving people the tools to advocate for themselves. These two examples both illustrate this core belief in public health, which is that you can identify risk factors and then empower individuals, as well as change society.

Part of the public-health approach is also saying that we’re not going to get to zero. If we could go back to the number of gun injuries and deaths that we had 10 years ago? We’d be looking at 40 percent fewer than we have today. But it requires moving beyond this all-or-nothing approach.

Wu: And yet, gun violence is so often framed in the arena of policy—of which laws are and are not being passed. Why isn’t that enough on its own?

Ranney: Policies are so important in public health. But they are only as effective as the community norms in which those policies are passed. An example: Safe storage is one of the most important things that we can do to reduce risk of firearm suicide and homicide. Most youths who kill themselves with a gun use a family member’s gun. Most youths who commit a school shooting use a family member’s gun. Safe storage—making sure that your gun is locked up and not accessible to your kid—is a major way to prevent that. Safe storage is also important in terms of reducing the flow of illegal guns on the streets, which causes firearm homicide. We’ve seen a skyrocketing number of guns being stolen from cars because they’re not being stored safely in those cars.

In order to get folks to store guns safely, policies can make a difference. But more important is the firearm-owning community standing up for how important safe storage is—making this part of the purchase of a gun, part of the community norm around firearm ownership, and part of a discussion between friends or family members. And that second part is the public-health approach. It’s about not putting all of our eggs in the basket of policy, but instead thinking also about the structural drivers. And it’s about involving the very communities that most need to be at the table in order to reduce the risk of injury and death, which is gun owners.

Wu: So what are some actionable steps that can be taken, within this public-health framework?

Ranney: One of the biggest things that we can invest in is data. For more than 20 years, there was pretty much no federal funding for firearm-injury-prevention research. As a result, the evidence behind how to stop firearm injuries before they happen stalled. We’re basically in the same place that we were in the 1990s. Imagine if that were true for heart disease or for HIV. That would be unacceptable. In the last few years, we’ve finally restarted firearm-injury-prevention research. There’s no way that we’re going to make sustained, real change without investing in collecting the data. That’s not going to change the numbers of kids who are in danger tomorrow, but it’s an essential part of bending the curve on this disease for the long term.

The other structural solution is again to stand up for the fact that public health matters. Making sure that your local public-health department is budgeted for adequately and that community organizations are supported makes a difference. It’s about getting both sides of the table and creating partnerships between firearm owners and non–firearm owners that can help to identify those at risk and reduce the risk.

Wu: What changes can begin immediately at the individual and community levels?

Ranney: The first thing is to allow yourself time to grieve. You can also talk to your kids, both to help them process what has happened and to be a safe space for them if they notice something concerning about a friend, either on social media or in school. The second thing is that if you yourself are a firearm owner, or if you have a family or are in a neighborhood where firearms are common, you can have discussions about safe storage, about how to identify risk factors, and about how to help the start to change cultural norms around what safe, responsible firearm ownership looks like and how to reduce the risk of gun misuse.

The third thing that you can do today is to get involved in community organizations that help to create those spaces that look out for each other. One of the biggest predictors of violence is being isolated. The way that we address that is by getting together long before the shooting happens. Some of the best ways to reduce violence are around things like Boys & Girls Clubs, or putting in place community gardens. A great example is the work that a colleague of mine, Eugenia South, is doing in Philadelphia, around greening vacant lots. When you put in a community garden, you not only decrease the number of firearms injuries in that neighborhood, but you also decrease stress, depression, and other problems as well. It’s a very discreet and doable intervention that can help shift the patterns for our community. Yes, policy change matters, and letting your congresspeople know that certain policies make a big difference, but there are things you can do long before you get there.

Wu: We’ve seen what a public-health approach can do these past two years, and also what happens when we don’t take it seriously. Has COVID shifted your approach to gun violence?

Ranney: There are a few lessons that stick out. One is the importance of community involvement, clear communication, and trusted messengers from the get-go. We developed amazing vaccines, but we never did the work to make sure that folks trusted them, to make sure that they were accessible, and to make sure that we were prepared to combat not only disinformation but also an absence of information that continues to plague many communities across the United States. And the same thing can be applied to firearm injury. We cannot fix this problem if we don’t pay attention to the communities and the people living in those communities in which gun deaths happen—if we don’t have their voices elevated and have them out there talking about why and how to prevent gun deaths.

Another is around harm reduction: allowing people to live their lives in a way that reduces the risk of infection and death, in the context of COVID. How do we reduce deaths instead of trying to get them to zero? We saw this all-or-nothing attitude during COVID, and it really hurt our ability in the U.S. to get COVID under control. The same is true for firearms. Anyone who thinks that we are going to get rid of firearms in this country is not living in the United States that I live in. Some absolutist nirvana is never going to happen. Instead, everyone needs to work with communities to create solutions that creep forward progress.

I’ve seen really clear examples of how you can make progress on these seemingly divisive issues. It takes time and hard work, but it is possible. And what choice do we have? It’s so easy to just dismiss this as another tragedy that you kind of feel hopeless about, and go on with your day. Knowing that there are both big-picture things that you can do, but also small-picture things that you can do, is essential. These kids and all the people who die every day deserve better than for us to forget them.


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