Targeting Youth Violence With Advocacy, Research

Healthcare practitioners at children’s hospitals have a unique and powerful perspective about firearms violence because they witness the devastation that it causes families on a daily basis.

Michael L. Nance, MD, director of the pediatric trauma program and an investigator for the Center for Injury Research and Prevention at The Children’s Hospital of Philadelphia, recently updated the American Pediatric Surgical Association’s (APSA) position statement on firearms injury and children, in response to the 2012 tragedy at Sandy Hook Elementary School. Dr. Nance is still haunted by pictures of the mass shooting in Newport, Conn., that killed 20 children and six adults.

“I find that I can’t turn away from it because I’m worried that I’ll somehow lose sight of the fact that we still have a huge problem and a lot of work ahead of us,” said Dr. Nance, who has been involved in the care of firearms injuries for more than 25 years. “It’s not just these mass shootings that are causing trouble … it is this daily drip, drip, drip of firearm injuries that is the real problem, and by the end of the year, another 30,000 Americans have died.”

Firearms remain the second leading cause of trauma death in the pediatric population. Since 1999, more than 35,000 children under age 19 have died as a result of a firearms injury. In 2010, 2,711 children died by gunshot, with another 15,576 injured.

The Sandy Hook shooting is especially disturbing to Dr. Nance as a surgeon because not a single child survived long enough to receive medical attention that day. The shooter used an assault-style rifle with a high-capacity magazine, and 18 of the 20 children had multiple gunshot wounds.

“So all the systems that we put in place, all this advanced medical care, couldn’t have helped save one of those kids,” Dr. Nance said. “Something has to change, and I think that what has to change in part is advocacy.”

At the time of Sandy Hook, Dr. Nance was chairman of the trauma committee for the APSA, a professional organization of more than 1,200 surgeons who care for young victims of gun violence. In a perspectives article published in the March issue of Pediatrics, he noted that the APSA membership took an unprecedented step by voting to endorse, as an association, the revised position statement to strengthen its message: Firearms-related injury and death must be addressed as a public health issue.

Among its nine position points, the APSA called on Congress to restore funding for firearms-related research. In 1997, an appropriations bill stated: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Congress expanded this language in 2003 and later broadly applied it to the National Institutes of Health, effectively shutting down any federally funded firearms-related research. Research dollars have trickled in from a few nonprofits, but the intellectual pool of investigators willing to pursue careers in gun violence research has dried up.

“The moratorium has effectively killed off generations of researchers,” Dr. Nance said. “We’ve had very little funding to do the research, and so we have very little data to go on except body counts — we know how many children are dead.”

President Obama ended the 17-year ban on gun violence research at the CDC when he signed a series of gun safety executive orders in January 2013. One of those orders issued a Presidential Memorandum directing the CDC to research the causes and prevention of gun violence.

It is too soon to tell if the executive order will make a difference in firearms research funding, Dr. Nance said, but he emphasized that data are crucial in trying to understand a problem as complex as firearms injury and desperately needed to accurately inform policy decisions.

“We don’t even have a simple understanding from a pediatric perspective of where the guns are, how they’re accessed, and how that access impacts injury,” Dr. Nance said.

The Institute of Medicine of the National Academies proposed a public health research agenda to reduce the threat of firearms-related violence. Several priorities focus specifically on children, such as determining the effectiveness of childhood education and prevention programs.

For its part, the Children’s Hospital of Philadelphia launched the Violence Prevention Initiative (VPI) in January, which is taking a hospital-wide, multidisciplinary approach to curb youth violence in all forms and keep children safe. The VPI’s Signature Programs will use research protocols to develop proof-of-concept ways that address different aspects of violence and then incorporate these evidence-based interventions into daily practices that interrupt the cycle of violence.

No other institution is “better prepared to lead this very important work, which has the potential to make a difference for children in communities across the United States,” said Children’s Hospital CEO Steven M. Altschuler, MD.