A UC Davis emergency medicine physician and his research program have played a pioneering role in studying gun violence as a public health problem — despite a two-decade nationwide funding drought. New state support will help such efforts even more.

Among the leading killers of Americans besides disease, guns can lend themselves to some pretty powerful statistical anecdotes.

Firearm violence currently results in more than 30,000 deaths per year in the U.S. and roughly 75,000 nonfatal injuries. That means we treat or bury nearly 300 persons per day on average — about the capacity of a mid-sized airliner — who find themselves “on the wrong end of a gun” through homicide and assault, suicide and non-fatal self-injury, or unintentional injury.

Or consider that civilian fatalities from gunshot wounds in the U.S. between 2005 and 2014 outnumbered our combat fatalities from World War II.

To observers such as UC Davis emergency medicine physician and violence researcher Garen Wintemute, what’s concerning about gun deaths isn’t just the volume — it’s also a relative lack of improvement. While issues such as highway safety and cancer survivability have generally changed for the better over time at the national level, gun death rates haven’t necessarily followed suit.

The mortality rate for U.S. motor vehicle traffic injuries, for instance — the focus of a dedicated federal agency, epidemiological studies, new technologies and safety regulations — has dropped by more than half in the past 50 years. Over the same period, gun mortality rates have fluctuated but on balance have risen slightly. In 2014, the age-adjusted death rate for both was the same for the first time in more than 60 years — around 10.3 deaths per 100,000 Americans.

“The reduction in auto deaths is considered one of the great public-health successes of the 20th century — and a rapid increase in death rates was halted in just a few years,” said Wintemute, who is the longtime director of the UC Davis Violence Prevention Research Program.

“It was really remarkable, and they still have structures in place to collect good data that can help continued improvement and enforcement.

“In contrast, the death rate from firearm violence, including homicide and suicide, has not budged in 15 years... And now the lines overlap.”

It’s a trend he still hopes to help change. Such statistics — and the associated human suffering that plays out in U.S. trauma centers — are among the reasons Wintemute (M.D. ’77) became an injury epidemiology pioneer when he began addressing firearm violence prevention from a public health perspective back in 1982. He is now one of the nation’s foremost scholars on the subject via his 25-year-old Violence Prevention Research Program.

Newly approved — and unprecedented — state funding for UC-overseen gun violence research will help support such efforts even more.

A public health problem

To Wintemute and other proponents of the public health approach to violence prevention, gun injuries and deaths are akin to those caused by pollution, prescription drug overdoses, tobacco use or car crashes — social problems whose causes and costs should be examined in a scientific manner to help guide appropriate intervention by policymakers, industry, communities and others.

“Gun violence is a public health problem,” Wintemute said. “Many people die from it and many more are injured. People are put at risk. And communities are devastated.”

Organizations representing many of the nation’s physicians agree. A coalition of eight major U.S. health associations, including the American College of Physicians and the American Academy of Pediatrics, noted in a 2015 Annals of Internal Medicine call to action that “many physicians and other health professionals recognize that this is not just a criminal violence issue, but also a major public health problem.”

This spring another collection of health care, public health, scientific and advocacy organizations, including the American Medical Association, called gun violence “a serious public health epidemic” in a request to lawmakers to open up Centers for Disease Control-led research on the topic.

With that funding on hold in Congress, California lawmakers acted in historic fashion to drive more gun research. The state budget they adopted this summer includes $5 million to establish a firearm violence research center at the University of California system — reportedly the first such center in the nation to be publicly chartered.

The initial funding is meant to support the center’s first five years of operation; as of the time of this writing, specifics were still pending about how and where it will be sited and operated among UC campuses. But the money will in effect provide support for efforts like those at Wintemute’s existing center, which is currently funded largely by private and foundation donations — including more than $1 million from Wintemute’s own pockets.

“Californians already benefit from the many years of research performed at UC Davis’ Violence Prevention Research Center,” said state Sen. Lois Wolk (D-Davis), who introduced the initial legislation this year proposing a state-funded center run through the UC system, upon approval of the funding. “We know that by using real data and scientific methods, our best researchers can help policy makers get past the politics and find real answers to this public health crisis to help save lives — in California and throughout the country.”

(Note: since the print deadline of the fall 2016 issue of UC Davis Medicine magazine, UC President Janet Napolitano announced her intent to establish the University of California Firearm Violence Research Center at UC Davis’ Sacramento campus under the direction of Garen Wintemute. Read the press release here)

‘Hero of medicine’

Wintemute himself began trying to understand the nature of gun violence and its underlying causes in the 1980s, and has since produced a uniquely rich and informative body of research on aspects ranging from unintentional child deaths to regulatory loopholes to suicides. The data, insights and context have helped to fuel increased awareness, changes within the firearms industry, innovative legislation to prevent easy access to guns used in crime, and other impacts (see sidebar).

Wintemute has published or contributed to more than 100 journal articles, studies and papers on firearmviolence, and has consulted on the topic for government agencies such as the National Institute of Justice, the Bureau of Alcohol, Tobacco and Firearms and CDC (as well as on other injury-prevention subjects for the World Health Organization and American Red Cross).

He has also testified before Congress, the California legislature and local governments, and is regularly solicited for comment by major media (in recent years, especially after high-profile mass shootings).

There have been many twists and turns along the way. Among positives are major contributions to policy decisions, such as bans on lifelike toy guns and “Saturday night specials” (cheap and easily concealed weapons disproportionately used in crimes); gestures of appreciation, such as a late-1990s nod from TIME magazine as a “hero of medicine” and a career award from the American Public Health Association; and top honors from the UC Davis and UC Davis School of Medicine alumni associations.

The negatives include hate mail and death threats, frustrating barriers to information access, and a highly politicized funding environment — one so dry that Wintemute was forced to spend personal funds in recent years to keep the work going. The ultimate disappointment remains the stream of victims.

Preventive care

It was partially clinical experiences that helped motivate Wintemute in the 1980s to be among the first to look at the problem of guns and violence as a public-health issue and emphasize the importance of prevention.

Wintemute earned his M.D. in 1977 from UC Davis, where he also completed a residency in family medicine. In 1981 he worked as a medical coordinator at a refugee camp in Cambodia, treating gunshots and other grievous wounds in a remote area only recently liberated from Pol Pot’s Khmer Rouge. He returned stateside to merge his medical training with public policy and earned an M.P.H. at Johns Hopkins in 1983. (His endowed chair, the Susan P. Baker-Stephen P. Teret Chair in Violence Prevention, is named after mentors there).

At that time, guns and the violence associated with them were largely considered mental-health or crime problems. But after returning to UC Davis Medical Center to work as a front-line emergency physician, Wintemute realized firsthand what statistics illustrate — there is often little that even modern medicine can do about gunshot wounds.

“It’s important to do both clinical work and research — each informs the other,” he said. “The clinical work is a very direct reminder of why I do the research, and the research lets me help in ways beyond those available to me as a clinician.

“People often assume that we get used to seeing the suffering that violence produces, but with any luck we don’t; direct exposure to the profound injustice that underlies violence is part of what drives us forward.”

In the evidence business

Wintemute and colleagues decided to tackle the issue as other public health scientists do: via research.

His initial work in the 1980s about unintentional deaths — including children accidentally shot by other children — gained traction and results. Since then Wintemute has continued to study the impacts on innocent victims, including people harmed by domestic violence and stray bullets. He also has become nationally known for going undercover to gather insights and data at gun stores, pawn shops and gun shows.

Today his Violence Prevention Research Program is a multi-disciplinary research and policy development effort focused on causes, consequences and prevention, with particular emphasis on firearm violence and its relationship to substance abuse and mental illness. The program disseminates research to help inform intervention decisions, and also measures downstream effects of policies; studies can variously mine government cause-of-death data and criminal justice statistics, examine gun-market structures, and — when such data is not restricted — evaluate violence prevention policies and programs.

“We’re in the evidence business,” Wintemute said. “When the time comes that there is support for action on a topic, we all hope that policy makers and rule makers will use evidence to make their decisions. Our job, very simply, is to do everything we can to be sure that when leaders come looking for that evidence, it’s there waiting for them.”

Because a public-health focus does include the specter of intervention — there is a root problem to be acted on or “solved,” after all — Wintemute’s efforts often draw the ire of gun-control opponents wary of rights reductions or government intrusion on the issue, or concerned that self-defense and other possible benefits are not given enough attention.

But sometimes his findings anger gun-control advocates as well — for example, when analyses have revealed a buyback program’s lack of impact on community-wide violence, or highlighted the limitations of requiring background checks for purchases at gun shows.

“The results weren’t surprising, at least to me, but they ran counter to a political agenda that some people may think I identify with — and I don’t,” Wintemute said. “If the research findings don’t match a particular political agenda, then so be it. The agenda has to be modified.”

On a shoestring

Politics are a major reason Wintemute has conducted his work in the midst of a nearly two-decade paucity of federal funding for gun violence studies that has discouraged many other scientists.

Federal dollars from agencies like the CDC — a mainstay of other public health research — have been heavily limited or nonexistent in the wake of Congressional actions in the 1990s. Last year an Associated Press estimate put the annual total for all U.S. gun violence research projects at about $5 million, and Wintemute has projected there are only about a dozen full-time gun violence researchers in the country.

Wintemute said independence and objectivity are important enough that he will not accept funding from advocacy organizations, and has declined it more than once. To help fill the gap, Wintemute, who lives simply and has no children, has given more than $1 million of his personal funds to support the UC Davis program through the long pause in government funding.

“I made the decision to help support the research for the same reasons I got into the field in the first place,” he said. “The burden of violence falls on millions of people every year, one way or another, and nowhere near enough work is being done to prevent it.”

Overall funding from the National Institutes of Health and nonprofit foundations has begun to increase somewhat in recent years in the wake of high-profile mass shootings, Wintemute said, although it’s still tenuous and a relative trickle in comparison to grants for other issues.

“What the public mass shootings have done is make it clear to everyone — not just those in highly impacted communities — that firearms violence can affect anyone, that they’re also at risk,” he said. “It’s transformed the way the country thinks about the problem.”

The 2012 Sandy Hook Elementary School massacre that killed 20 young children in Newtown, Conn., was particularly powerful in this regard, Wintemute said; he recalls a physician colleague approaching him afterwards to offer research assistance, declaring “I want a piece of this.”

He received similar offers after this June’s mass shooting in Orlando, Fla., at press time regarded as the largest such tragedy in the nation’s history. And within a week of the shooting, California lawmakers moved to approve already-proposed legislative measures funding the state’s new firearm violence research center.

‘No easy, simple fix’

Meanwhile the UC Davis Violence Prevention Research Program had already been expanding in both size and scope, working to enhance depth of understanding about potential determinants of violence such as alcohol and drug abuse.

“Violence is a very complex problem with a lot of factors and modifiers, and the response has to reflect that,” Wintemute said. “There is an array of approaches that can be taken, and an array should be taken. There’s no easy, simple fix.”

Last year Wintemute recruited an associate director, Magdalena Cerdá, an internationally known social epidemiologist with special expertise in violence and substance abuse research. Cerdá, who earned a doctorate in social epidemiology from Harvard and completed a prestigious Robert Wood Johnson Foundation postdoctoral fellowship, integrates approaches from social and psychiatric epidemiology to examine how social contexts shape violent behavior, substance use and mental illness.

“As I started work on violence prevention, I began to realize that the same people facing problems with violence were having problems with drug and alcohol abuse and to a certain extent with mental illness,” Cerdá said. “I want to find out the common causes of all of these correlated problems, and figure out how we can intervene to have a cross-cutting impact across violence, substance abuse and mental illness.”

One current study will evaluate prescription drug monitoring programs to assess which types of programs are most likely to reduce drug overdoses. Another will simulate and compare different firearm disqualification criteria in New York City to determine how they affect homicide and suicide.

“Although there’s a link between mental illness and violence, it’s actually a very weak link,” Cerdá said. “How much of an impact would disqualifying people with mental illness from owning firearms have on firearm violence? How does the impact of disqualifying people based on mental illness compare to the impact of disqualifying people based on strong predictors of violence, such as drug and alcohol abuse?”

Wintemute and Cerdá also have existing plans to add an additional full-time social epidemiologist and a criminologist in coming months, and have created a fellowship program to train future investigators.

“We started as a small unit and are growing exponentially,” Cerdá said. “We’re creating a program with a research agenda that focuses on violence but also examines its links with substance abuse and mental illness, and that’s really exciting.

“And because of our location in the state capital, there’s a lot of potential for research that’s relevant to policy and that can help inform policy.”

Read more:

Turning point: Gun-crime analyst. Nature online, March 2016

Firearms research: The gun fighter. Nature, April 2013