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Aiming for Change

A new initiative at U-M has empowered public health researchers to find public health solutions to the problem of firearm injury.
By Amy Crawford

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Rebecca Cunningham speaks about firearm safety with the urgency of someone who has seen her share of bullet wounds. An emergency physician, she has routinely cared for victims of gun violence, working with a team of doctors and nurses to staunch blood loss, clear airways, and stabilize patients so they can survive the operating room. After that, another medical team does its best to repair the damage.

Among the trauma that might bring a person to the emergency room, firearm injuries are especially devastating—at best, they leave people with physical disfiguration and psychological scars that can last a lifetime. But it’s the patients Cunningham couldn’t save who haunt her.

“Not one specific patient,” she explains, “but the recurring need to go and sit in small waiting rooms with the families and tell them that there was nothing we could do for their children or teenagers. Those were just senseless deaths, senseless losses for these families.”

Nearly 40,000 Americans die each year by gun violence—more than in traffic accidents—according to the Centers for Disease Control (CDC). But unlike other deadly threats, firearms hold a unique place in American culture. To the 30% of American adults who own them, guns are tied to identity, community, and pride; to others, they represent only danger. With so much at stake for both sides, the polarizing political debates that guns inspire can be both fierce and unproductive.

Cunningham believes it doesn’t have to be that way.

“I don’t think this is a political issue at all, really,” says Cunningham, interim vice president for research and director of the U-M Injury Prevention Center. “What it is, is a giant public health problem. Public health problems generally have public health solutions, and this one is no different. But first you have to have some information about what works and what doesn’t work. Research can help us understand the problem.”

Over the past few years, U-M has become the country’s leading firearm injury research institution, accumulating the largest collection of firearm datasets and attracting more federal funding to study the issue than any other U.S. university—more than $6.5 million since 2017. Now, the newly launched, University-wide Firearm Injury Prevention Research Initiative, housed at the School of Public Health with Cunningham as lead planner, will draw on that expertise while developing collaborations with community groups and other institutions to build on what we know about how to reduce gun violence—and to put that into practice.

“The vast majority of Americans want fewer people dying by gun violence,” Cunningham says. “We can all agree that we have too many people dying right now. We’re asking, how are we going to make our families safer? How can we work together?”

To answer some of these questions, researchers are looking to the past—specifically the largely successful battle waged against another form of trauma.

THE AUTOMOBILE MADE ITS FIRST APPEARANCE in the late 19th century, quickly revolutionizing American life—for better and worse. By 1966, some 2 million Americans had been killed in crashes. That year, Congress created a new agency, the National Highway Safety Bureau, which would take a radical new approach to what had become an accepted peril of modern life.

The new agency’s first director, public health physician William Haddon, saw traffic accidents as similar to disease outbreaks. As with earlier campaigns against communicable diseases, he understood that examining the factors involved—the human “hosts,” the “agent” (in this case, an automobile), and the environment—would help shed light on what could be done to reduce death and injury, either through new regulations, better design, or educational campaigns designed to change behavior.

“We’re really working with the community to show us how we can best work on firearm safety.”

This public health approach led to many of the automotive safety features that we now take for granted, from seatbelts and airbags to crumple zones and shatter-proof glass. Roadways are now engineered with safety in mind, and laws and educational campaigns have curbed dangerous behaviors like drunken driving. And these interventions worked: By 2019, fatalities per vehicle-mile traveled had fallen by 80% since 1966.

This staggering reduction in traffic deaths is one of public health’s greatest victories, and it carries a lesson about how to tackle firearm injuries.

There remains, however, a lot to learn. Just how much was made clear last August in a special issue of the Journal of Behavioral Medicine that focused exclusively on research by members of Firearm Safety Among Children and Teens (FACTS), a consortium based at U-M and co-led by Cunningham. To assess the current situation, researchers at U-M and elsewhere examined research since 1985, finding only a handful of rigorous studies about youth and firearm injury risk.

A few risk factors for gun injury or death did emerge from the research, including abuse of alcohol or marijuana and previous involvement in violence. Increased suicide risk was tied to living in a home with a gun—especially if it was unsecured. But while parent education, combined with the distribution of free gun locks, did seem to increase safe storage rates, how much that actually reduces gun injuries was unclear. There was no conclusive evidence about how best to educate young people directly, and while some laws intended to reduce children’s access to guns seemed to help, a lack of data on gun incidents nationwide hampers this research. And that’s just young people—research about how gun violence affects adults is even more sparse.

“There are so many questions to be answered,” says Patrick Carter, U-M assistant professor of emergency medicine who is also on the FACTS leadership team. “What’s the most effective intervention for folks who are at risk for suicide? What can we do for communities that have high levels of interpersonal violence? Are there effective interventions that can be scaled up? What policies do work? What’s not effective?”

While public health researchers may consider their work apolitical, politics have factored into their efforts to better understand gun violence. A 1993 paper in the New England Journal of Medicine revealed a correlation between the presence of guns in a home and the risk of a homicide taking place there. The National Center for Injury Prevention and Control (NCIPC) at the CDC funded the research, which prompted the National Rifle Association to push for the NCIPC’s elimination. In 1996, Congress responded by passing legislation known as the Dickey Amendment, which required that “none of the funds made available for injury prevention and control at the (CDC) may be used to advocate or promote gun control.”

The Dickey Amendment effectively shut down federal funding for research into gun violence prevention until 2018, when Congress revised the legislation. And it was only last year, when Congress passed the federal budget for 2020, that any money was specifically earmarked for firearms research.

“You need epidemiological data to be able to really think about the precursors, the risk factors, and the situations where firearm injuries are more likely or less likely to happen,” explains Marc Zimmerman, a professor at U-M’s School of Public Health and a co-director—with Cunningham and Carter—of FACTS.

IN MICHIGAN’S UPPER PENINSULA, people often pass down guns through their families. They use them to hunt and protect themselves against wild animals, and they take pride in their ability to use guns safely. But there is a dark side. According to CDC statistics, America’s most sparsely populated communities suffer from suicide rates that may be twice as high as in large metropolitan areas. More than half of these deaths involve guns, which means getting people to store their firearms safely—a suicide prevention strategy known as “means restriction”—is imperative. And the best way to get that message out in rural areas has proven elusive.

“For a lot of people up here, a firearm is a tool,” says Sarah Derwin, a health educator with the Marquette County Health Department. “Even though we have data and statistics to show the relationship,” she says about guns and suicide, “firearm owners, I think, feel a little defensive about it.”

Derwin has been working with U-M researchers to lead a series of focus groups of Upper Peninsula gun owners. The involvement of someone with deep local ties has been invaluable, says Cheryl King, a U-M professor and director of the Youth and Young Adult Depression and Suicide Prevention Research Program. “Community members are sharing a great deal about their views and thoughts, why they have guns, what they think should happen. We’re really working with the community to show us how we can best work on firearm safety.”

One surprising takeaway has been that, despite recommendations from physicians’ groups that doctors talk to patients and families about the presence of guns in the home, not all gun owners believe health care workers are the community members who will have the most impact delivering messages about safe gun storage. And despite nationwide concern about violence in schools, some perceived the educational system as too political and too focused on the scare of school violence to deliver a message about the importance of safe storage of firearms at home.

“We can all agree that we have too many people dying right now. We’re asking, how are we going to make our families safer?”

Instead, it turned out, people indicated they would be most receptive to the conversation when it was initiated by other gun owners, whether hunters or people with professional firearms experience, such as police officers or former members of the military. The next step, King says, is to pore through the focus group transcripts and use the data to develop messaging about gun safety. Those messages could be delivered in person or via video by respected community members with significant firearm experience and their family members and be piloted in the Upper Peninsula. If effective, this strategy could be deployed more widely in other rural areas.

With firearm injury, like other public health challenges, it turns out context is key—and that’s something U-M researchers are finding in cities as well. A recent U-M study of neighborhoods in Flint, Michigan, found that beautifying vacant lots—cleaning up trash, mowing grass, or adding gardens—reduced assaults and other violent crime by nearly 40 percent, compared with streets where vacant lots had not been cleaned up. (The study did not distinguish between gun-related incidents and other forms of violence, but the authors noted that lower-level conflicts often precede gun crimes, which suggests that any reduction in violence can help reduce firearm injuries.)

“What I was really excited about is that it didn’t take much to find the effects,” says senior researcher Justin Heinze, an assistant professor at the U-M School of Public Health. “Demolishing dilapidated buildings? Yes. Creating a very nice park? That seems to work. Community gardens seem to work. Even just mowing lawns and getting rid of overgrown bushes seems to work.”

The study looked at a program created by the Genesee County Land Bank authority, which recruited local residents as volunteers. While the researchers weren’t sure what exactly caused the reduction in crime, they hypothesized that seeing neighbors working outside to improve their surroundings promoted a sense of community. One next step will be to determine whether this positive effect holds if outsiders are hired to do the work instead. Eventually, Flint’s success may inform other cities’ efforts to reduce violence by redesigning the urban environment.

“There’s still a lot of missing groundwork,” Heinze notes, adding that the new U-M initiative should help remedy that. “When you see an institution like the University of Michigan saying, ‘Yes, this is important,’ that makes it a lot easier for us as researchers to go out and talk to people about what has been a taboo subject. I think that’s huge.”

King, who has been working on youth suicide prevention for more than 30 years, is also hopeful, although she admits dismay at the lack of progress so far, as nearly 40,000 Americans are still dying every year by gun violence.

Still, King and her colleagues find hope in one of public health’s greatest victories, over something that also once seemed an unalterable element of American culture.

“When I was a kid, a long time ago, they used to throw us in the back of a pickup, and we bounced around on the wheel beds,” she says. “You wouldn’t think of doing that now. So these things take a lot of time, and it can’t be people like me or our university telling people what they should do. First, we have to have some model strategies, and I think research will get us there. Then it has to come from the community, and that’s cultural change.”


Amy Crawford is a freelance writer whose work has appeared in Smithsonian, The Boston Globe, and Nature Conservancy magazine. Follow her on Twitter @amymcrawf.

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