Gun violence: A reckoning

“I am on call Wednesday night. The statistics indicate that then I will once again walk with the chaplain to a small room off the emergency room. I will open a heavy brown door and make eye contact with a room full of people; a mother, perhaps a father or a grandmother. They will look at me with tears welling up, their knees weak, and lean forward while watching my lips, bracing for news about their loved one. I will remain standing and reach out to hold the mother’s hand. My announcement will be short and firm, the intonation polished from years of practice. The words will be simple for me to say, but sharp as a sword for them to hear; ‘I am sorry, your son has died.’”

John P. Pryor, MD, who directed the trauma program at Penn Medicine’s Level 1 Trauma Center then at the Hospital of the University of Pennsylvania, wrote these words in the Washington Post in 2007. His essay decried the public’s “triage of compassion and empathy” that made them feel sympathy for the victims of mass casualty events he treated as a U.S. Army combat surgeon, but turn a blind eye to the daily deaths in the “War in West Philadelphia,” as he titled his piece.

That war had raged on for decades—and continues—not just locally in Penn’s surrounding communities, but as a distinctive national problem, according to C. William Schwab, MD, the founding chief of Trauma Surgery at Penn Medicine, now an emeritus professor.

“This is an American problem, something we see in almost no other country in the world, but it’s not a civil war,” he said. “It’s an uncivil war. It’s people against people shooting one another.”

Today, Penn’s trauma center is located at Penn Presbyterian Medical Center and named for Pryor, who was killed in the line of duty in Iraq just two years after decrying the “War in West Philadelphia.” At the John Paul Pryor, MD, Shock Trauma and Resuscitation Unit, physicians continue seeing a flood of patients who have been gunned down, mostly young Black men. By late August 2021, when over 1,500 people had been shot in Philadelphia, nearly 300 of them fatally, the Philadelphia Inquirer editorial board noted that there had been shootings every day that year, save one (January 2). The near-daily onslaught flowed through the fall; by mid-November, only three days of 2021 had been free of a recorded shooting.

Though the crisis has been long and remains profound, from Schwab’s vantage point today, there is hope.

Public apathy has been one of the biggest challenges to ending gun violence over the decades that Schwab has been studying the problem in response to seeing a flood of patients in the trauma center with fatal and nonfatal gunshot injuries. Too many people, he said, see the problem as “just a part of American life.”

But that was far from the only challenge. In the mid-1990s, federal spending budgets began to include an amendment that blocked government funding of research that could be used to promote gun control—chilling scientific efforts to understand, prevent, and respond to these violent deaths and injuries.

That chill didn’t deter Schwab and Therese Richmond, PhD, RN, of Penn Nursing. Together, around that same time, they co-founded the interdisciplinary center now known as the Penn Injury Science Center, where today Richmond remains the director of research. “When we did that, it was him and me,” Richmond said. “We were the people focusing on gun violence. It was not broadly looked at, not something a lot of people on campus were interested in.”

Schwab, as a trauma surgeon, and Richmond, as a trauma and critical care nurse, were confident in their mission. It was just as serious to address gunshot wounds at their root cause, they reasoned, as it was for heart attacks—both a major cause of emergency department care and sudden deaths. “What if in health care we didn’t fund research in cardiovascular health problems or stopped for 10 years because it’s not politically favorable?” Richmond asked. “What if we didn’t think beyond what brings you in with a heart attack and work to understand and treat blood pressure and cholesterol? If we didn’t do it, people would say we’re negligent.”

They built a community of scholars across disciplines at Penn, connected to collaborators around the country, spanning epidemiology, trauma and emergency medicine and nursing, pediatrics, psychiatry, psychology, and more disciplines. “We started as a mom and pop shop with $10,000,” Richmond said. “With the support of foundations we were fortunate to escalate our support to several million dollars that allowed us to grow the science, recruit new faculty, and develop the next generations of scholars interested in studying gun violence.”

The need for understanding and acting to end gun violence is as great as ever as the casualty count continues to grow. For the physicians who continue to treat these violent traumas, every night on call becomes a night they are prepared to face a family’s tragedy, just as it was for Pryor in 2007, and as it was in the mid-1990s, when Richmond and Schwab saw the need to unite under a new research center.

But the landscape of battle has shifted: The uncivil war of gun violence has converged with the COVID-19 pandemic, as well as with the rising movement for racial justice. In 2021, too, U.S. federal agencies have once again begun distributing grants for research into gun violence, the freeze on such funding now thawed after nearly two decades.

And there are also new opportunities for change. This fall, the Penn Injury Science Center and Penn Trauma were among the partners forming a new West/Southwest Collaborative Response to Gun Violence of community, university, health system, and government stakeholders to address gun violence together in Philadelphia.

They are building on years of steady effort to understand and stop the violence. Schwab cites the growth of federal data on fatal and nonfatal injuries—begun as a pilot program in nine states in the 1990s, now representing 30 states—as a huge step forward over the last two decades.

“It is two things: Having more data and more young scientists who are now able to fund their work are rays of optimism,” Schwab said.

The seeds of injury science scholarship planted by Schwab and Richmond in the 1990s have grown into what Richmond describes as a “vibrant ecosystem” that is well-situated to try novel strategies. “One of the places we have watched evolve over the past two decades is a much stronger recognition that one of the most significant contributors to gun violence is social determinants,” she said. “Inequalities in neighborhood opportunities, intense poverty, investment in some areas of the city and disinvestment in others, leave some populations marginalized and at higher risk.” This wider social view opens up perspectives to understand and try social interventions that may have nothing to do with guns, from prevention by investing in neighborhood green spaces to social service support to help victims recover from psychological harm, and communities to heal.

At this pivotal moment—mired in a long and deepening crisis, yet informed by more years of insight from new angles—four individuals at the front line of the uncivil war today share their perspectives in a set of thoughtful essays. You will meet:

• An emergency physician who emphasizes the profound pain for of her Black colleagues seeing Black bodies – including friends and neighbors—on gurneys night after night.
• A mother who recounts her family’s and community’s decade-long emergence from an impossible loss.
• A trauma surgeon and researcher who acknowledges the long trajectory of recovery after patients leave the hospital, and how post-treatment intervention and prevention go hand-in-hand.
• A physician-scientist who draws a line between fears for her own young Black sons’ safety and research on the disproportionate impact of neighborhood-level investments in Black communities.

Collectively, these essays convey a breadth of research-backed insights, emotional impacts, and ongoing challenges that characterize the uncivil war of gun violence today. Though all four essayists work in health care, they emphasize that solutions will require collaboration with government, communities, and individuals across sectors. Their call to armistice is growing louder as more voices join in unison.