August 11th, 2019

The United States Needs Stricter Gun Control Now — and Yes, This Is an ID Issue

In general, I’ve tried to keep this site a pretty happy place.

It’s not been difficult. The ID and HIV community includes many smart, like-minded individuals involved in all sorts of interesting and challenging work, both domestically and abroad. As one of our ID fellows recalled, after he did a rotation in our ID clinic during his medical residency, “I realized I’d found my people.”

Today, however, I’m going to write about something on the sadder side, an issue tearing up our country.

We need stricter gun control in the United States. And we need it NOW.

Yes, this is a departure from prior controversies here, such as should doctors wear white coats, estimating the infectious risk of food tongs, or whether the correct abbreviation for P. jirovecii pneumonia is now PJP instead of PCP. 

I’m venturing into this more contentious* issue because it’s just too painful to ignore.

(*But to my dear readers of the ID persuasion, there’s an excellent chance you’re in complete agreement. And how do I know? Easy.)

How many of you thought, Oh no not again, when you heard the news of last week’s shooting in El Paso? And then less than 24 hours later, Oh no not again, with the news from Dayton?

And we could go on and on listing these mass shootings — sadly, we even have a Wikipedia page cataloguing them for us. It’s getting so bad that voices outside of the usual crowd feel compelled to weigh in — here’s sportswriter Joe Posnanski taking a break from his usual (brilliant) baseball coverage to write a poem describing his heartbreak.

It’s very moving. But a sportswriter writing a poem? Must be time to do something.

And lest some think this isn’t a problem related to Infectious Diseases, that I should “stay in my lane” — how wrong to think that. It’s a problem for all of us in healthcare, and, for several reasons, especially for us ID-specialists.

Crystal Zheng and David Mushatt, two ID doctors from New Orleans, astutely make the case:

During the initial hospitalization, gunshot wounds can become infected, causing skin and soft tissue infections, as well as intra-abdominal, thoracic, and brain abscesses ….Long after the initial event, gunshot survivors with spinal cord injury face a lifetime of disability, marked by recurrent infections due to autonomic dysfunction, decreased airway clearance, sensory loss, and paraplegia. These patients are at increased risk for urinary tract infections, pneumonias, infected sacral ulcers, and chronic osteomyelitis. Infection is the leading cause of death in this population. 

(Emphasis mine.)

Most of the cases we see, of course, aren’t from mass shootings. Events like El Paso and Dayton (and Gilroy and Newtown and Orlando and Parkland and Charlotte and Pittsburgh and …) get the big news, but there are way more injuries and deaths from individual shotgun wounds happening every day and night somewhere in our country.

For the victim, it doesn’t matter if the injury is from a mass shooting, an unfortunate urban skirmish, a heated domestic squabble, or the result of a deranged individual who has ready access to a gun. Their lives are irrevocably changed if they survive, often with infectious complications.

Yes, if they survive. If they don’t, those left behind suffer unbearable sadness and trauma at the loss — family, friends, colleagues. We have personal recent experience at our hospital when, in 2015, one of our rising stars in cardiac surgery was shot during an outpatient clinic session.

Oh no not again.

But look — it doesn’t have to be this way.

After last weekend’s events, I tweeted about the New Orleans perspective piece cited above, and received this response:

That’s right — 35 years of clinical ID practice, no gunshot wounds. Other countries have angry people. Other countries have urban violence. Other countries have terrorists. But only in the United States can these lead to such efficient killing.

And it’s the easy access to guns that makes our country an outlier in gun violence. It’s that simple:

I hope you’ll read the linked article, which debunks several popular alternative theories about why we have more gun violence (specifically mass shootings) than any other country. But if you don’t have the time:

Americans make up about 4.4 percent of the global population but own 42 percent of the world’s guns. From 1966 to 2012, 31 percent of the gunmen in mass shootings worldwide were American.

New Yorker writer Adam Gopnik has written frequently on this topic, perhaps because he lived in France, a place with far more sensible gun control. After the Orlando mass shooting in 2016, he wrote a piece called “One Person, One Gun” highlighting the horrible power we Americans grant our citizens — criminals, terrorists, people with mental illness, perpetrators of domestic violence — by giving them ready access to guns.

And it’s not just any handguns, but weapons designed for military use specifically to kill as many people as efficiently as possible:

So, yes, one person did do that, but it was a weapon that empowered him to do it—a weapon designed only for mass killing on the battlefield, a weapon so dangerous that soldiers keep their version locked up when not actually training with it, out of respect for its rapid-fire lethality, but a weapon that now, in Florida and elsewhere, can be placed freely and without constraints into the hands of almost anyone who wants one.

Last week, numerous medical organizations weighed in on the need for stricter gun control in this country, calling for specific actions that make so much sense it only adds to the pain that these restrictions are not already in place — among them, requiring background checks before sales, prohibiting gun ownership among those guilty of domestic violence, special regulation of high-capacity firearms, and removal of physician gag-orders on counseling about gun violence.

I can’t speak on behalf of the Infectious Diseases Society of America (our own medical society), even though I’m a member.

But I can unequivocally say that 100% of the ID clinicians I’ve spoken with agree that this is an urgent issue for all of us.

Take it away, Stephen. It may not be your funniest clip on the topic of gun control — search YouTube for “Stephen Colbert gun control”, there are plenty.

But it could be your most important.



23 Responses to “The United States Needs Stricter Gun Control Now — and Yes, This Is an ID Issue”

  1. Joe Maidl says:

    Sax makes some huge logical fallacies in this political hit piece. For starters he’s getting his information from the NY Times, the New Yorker, Wikipedia, Sports Illustrated, and Steven Colbert. That’s about as bad a start as possible. Then he extrapolates recommendations made by political lobby groups masquerading as legitimate clinical medicine organizations. I used better and more objective references for papers written in my high school AP English class.
    I’ll defer to Dr. Sax when it comes to the infectious disease implications of gunshot wounds. But he need not look any further than NYC and Chicago as outstanding subsets from which to draw the staggeringly obvious observation that gun control laws do not decrease gun violence.

    • Alex Crawley says:

      Hi Joe,

      You appear to be attacking the character of Dr. Sax’s sources, rather than the arguments his sources are making.

      Your argument appears to be that if somewhere like New York City passes gun legislation, bringing guns into the city becomes impossible. This argument would make sense only if NYC’s neighbours also had equivalent gun legislation – which they do not. Further, compared to countries like Australia, NYC’s gun laws are extremely modest. Thus you’ve created an unfair comparison.

      I live in Canada, and don’t have a horse in this race. Except to say that we Canadians often wonder how a rich, intelligent country like the United States could possibly inflict so much trauma on its citizens.

      Yours sincerely,


    • David says:

      Against my better judgement, I am responding to this probable troll.

      Joe wants us Dr. Sax and the rest of us docs to “stay in our lane,” and he takes issue with the evidence base Dr. Sax uses in this post.

      First, this is our lane, Joe. Did you read the post?

      Second, Joe, since you are so concerned about evidence, I’m sure you support more research into gun violence, and you oppose the federal freeze on CDC gun research, right?

  2. Andrew says:

    Joe, could you be more specific about which logical fallacies you see? Or are you just a troll?

    Bravo, Dr Sax. Thank you.

  3. Alejandro says:

    More guns …more shootings. Yes, USA needs gun control now.

  4. R H Jones says:

    When you’ve eliminated the hundreds of thousands killed by abortion and medical errors, then we’ll talk.

    • William Gailmard says:

      False equivalence. Try and do better next time. Stay focused on the topic and information presented.

  5. Bernhard Lämmle says:

    Thank you Dr. Sax, yes, I fully agree with your comments. And yes, congratulations for not “staying in your lane”

  6. Jason Halperin says:

    Dr. Sax –

    Thank you so much for this post. I have the honor of working with both Dr. Zheng and Dr. Mushatt and we bear witness daily to the impacts of gun violence on our communities. I am, primarily, an HIV clinician and it is vitally important to recognize how gun violence also impacts our HIV patients and the continuum of care. I regularly see patients who have been shot themselves or lost loved ones to gun violence and are now caring for dependents. My patients regularly live in fear of further violence. Medication adherence pales in comparison to this trauma.

    The intersections of HIV, stigmas and gun violence needs to be further explored.

    I was so heartened to see this latest editorial in the Annals of Internal Medicine signed by leading medical associations.

    I am disappointed that IDSA/HIVMA have not added their important voices. I requested a statement following the initial publication of the Zheng editorial and was told, respectfully, that this is not a priority area and that more research is needed.

    One of the reasons I love our specialty is that we look beyond our individual patient to public health solutions and advocate accordingly.

    I know we need to commit to prioritizing this research and, as we do, I look forward to our associations leading and for a future with less gun violence.

    Jason Halperin
    Tulane University
    New Orleans, Louisiana

  7. Cathy Corman says:

    In 1992, I wrote a magazine piece profiling every person killed by gunshot (other than by suicide) in one month in the state of Connecticut. I interviewed the state’s chief medical examiner at the time, who compared numbers of guns to bacteria in water. The higher the numbers, he said, the more people will get sick and die. I ended up doing a sidebar incorporating observations and comments of ER docs and trauma surgeons. They argued that the number of people killed by guns would be much higher were it not for such successful surgical interventions. The impact of gun violence, as you note, is so much larger and broader than any of us initially imagines.

    One of my sons texted today to say that another of the kids with whom he worked in Chicago three years ago was gunned down and killed. A 17-year-old kid. Shot fifteen times. My only hope is that this son can channel his despair and rage when he applies to earn a degree in social work. Can he make a difference? I don’t know. I worry that he, himself, could be in the line of fire.

    It is not a stretch of the imagination (nor a logical fallacy) to consider mass shootings and gun violence an epidemic in the United States. Yes, a public health concern. And, yes, a matter of concern for ID docs in this country. I hope physicians and health insurance executives are able to lobby successfully for a reduction in the amount of ammunition available for purchase in the US as well as for the numbers of guns on our streets.

    Keep going.

  8. Bill says:

    “Little Joe” attacking Dr Sax is very much like taking a knife to a gunfight. The irony of of that was too much to ignore.
    Dr Sax once again brings up great points.
    Please keep them coming

  9. Matt says:

    Well said. Gun ‘control’ IS healthcare’s lane. Whether it is treating victims immediately after or long term. Or even if it’s a “mental health problem, not a gun problem” as many like to say…still in healthcare’s realm.

  10. Christopher Courtney says:

    My understanding is that the homicide by firearm rate in the US is almost half the rate it was 25 years ago. The belief that “things are getting worse” is best explained by increased media coverage. Secondly, we could emulate Mexico, which enforces very strict gun control, but is not the most peaceful country. Thirdly, Dr. Sax is not arguing for the elimination of firearms, but restricting guns to the government, which has shot and killed far, far more people than all of the criminals in America in the past few decades.

  11. Kathleen Glaze says:

    Christopher Courtney, according to the CDC most current data firearm related deaths actually increased.

    “Firearm-related mortality
    In 2017, 39,773 persons died from firearm-related injuries
    in the United States (Tables 5, 6, 8, and I–3). In 2017, the age-
    adjusted death rate for firearm-related injuries for the total
    population increased significantly, by 1.7% from 11.8 in 2016 to
    12.0 in 2017 (Tables 5, 10, and I–3). For males in 2017, the age-
    adjusted death rate for firearm-related injuries was 6.1 times the
    rate for females. The rate for firearm-related mortality increased
    2.0% for males from 2016 to 2017. The rate for females in 2017
    was unchanged from 2016. The age-adjusted death rate for non-
    Hispanic white males was 54.9% lower than for non-Hispanic
    black males and 73.9% higher than for Hispanic males. The rate
    for non-Hispanic white females was 15.6% lower than for non-
    Hispanic black females and 111.1% higher than for Hispanic
    females.” National Vital Statistics Report vol 68 number 9 published 29, 2019

  12. Chuck Sheppard says:

    I hate to get in these conversations because they are mostly made up of people already committed but
    1 lumping all firearm deaths together makes no sense as the “treatment” is vastly different IMO the suicide patient might (or might not) be deterred (or changed to a less lethal means by a waiting period but not one of the mass shootings or gang shootings would have been.
    2. No increase in background checks would have prevented a mass shooting (unless the Air Force had reported the shooter in Texas (again not a failure of the background check) but maybe would catch some of the drug violence related, especially if we started punishing the straw buyers (girlfriends etc.)
    3. None of the mass shooters (again except Texas) would have been stopped by Red Flag laws although with proper safeguards are probably a good ide. They have resulted in some clearly innocent deaths however.
    4, The Secret Service National Threat Assessment Center report on prevention of Mass Attacks in Public Spaces (MAPS) has some great ideas for prevention (interestingly none involve “gun control”
    5. There have been several “apparent” mass shootings prevented by concealed carry people at the scene (some civilians and some off duty police/fire) and no evidence to date that CC people have increased the risk except for the Pulse nightclub shooter who was a security guard.
    If we are going to propose significant changes in the law (which have a history of going south more than actually working) should talk about which problem we are fixing and show that the proposed change would have prevented the event we are trying to prevent otherwise you are just grandstanding. So far as I said none of the proposals being put forward would have prevented a single one. As a note limiting capacity of the weapons is at best a marginal deterrent as with practice reloading takes less than 1-2 seconds and most of the mass shooters to date have spent a lot of time practicing. I hate these tragedies and feel the pain and totally agree this is all our lanes but don’t agree that we must “do something” without at least deciding on a rational/effective “thing to do”

    • Richard says:

      How about allowing federal funding for gun violence prevention research? You are probably correct in saying that background checks and other measures would have little medium term effect but for the wrong reason. These measures would be effective but for the already vast arsenal in the hands of 30% of the population. Buy back programs, strict licencing (stricter that driver’s license) may be of additional help. Hopefully the palpable insecurity brought by those events will lead to the eventual political defeat of the gun lobby just like the cigarette lobby was defeated.

    • William Gailmard says:

      The notion that we need prove causation, beyond correlation, when it comes to injuries and deaths from firearms in the United States smacks of yet another facet of exceptionalism. As this concept alone repeatedly appears as a “reason” to keep doing what we’ve always done, I feel confident dismissing it prima facia. The evidence that making firearm ownership more restricted decreases firearm injuries and deaths is overwhelming to all of us who fail to see the Second Amendment as a “God-given right.” The evidence that having a firearm in your home makes you less safe is overwhelming, but it is overwhelmingly ignored by the gun-loving minority and their corporate sponsors.

  13. Joshua Quaas says:

    Paul, thanks for taking on this difficult topic publicly. To echo some of the comments, “this is our lane”.

    Medical professionals witness first hand the carnage gun violence wreaks on people, families, and communities. And then we take care of the victims and their loved ones. Ask someone who works in the field about it.

  14. Manasa Velagapudi says:

    Thank You Dr. Sax for emphasizing this is “our lane “.

  15. Janaki Kuruppu says:

    I join the chorus of thanks for Dr. Sax bringing up this “contentious” topic. I share the amazement that an ID doc in Australia can practice 35+ years and not encounter a gunshot wound. One of the sadnesses of my clinical practice in Baltimore, MD, is the large number of patients in my clinic and hospital practice who sustain GSW, and suffer multiple surgeries and infectious complications, not to mention mental health consequences. I have taken care of at least half-a-dozen men and women who grieve for the death or disability caused to their children who were victims of gun violence.

    This issue is definitely in our lane – we need more research, we need sensible gun laws. Now!

  16. Peter H. Proctor, PhD,MD says:

    First, mass shootings are vanishingly rare. As a cause of mortality, roughly 0.3/million deaths. For perspective, compare this to the probability of a toddler drowning in a bucket, about 10/million. Astrophysicist Neil De Gras Tyson just raised a stir by similarly pointing out that there are orders-of-magnitude more common causes of mortality that no-one seems to worry about.

    Further, the literature does agree that mass shootings do act like a virulent epidemic. However, the generally-accepted vector is media reports, not firearms. For examples and cites, see: “The Infamy Game: Thoughts on How Not to Cover Mass Shootings” Also see: “Thresholds of Violence How school shootings catch on.”

    Basically, mass shootings are “Herostratic crimes”, named after Herostratus, who burned down the Temple of Artemis at Ephisos “So his name would live forever”. Rather than blaming the torch, the Ephesians made mention of his name a capital offense. Clearly, ineffective. but might be work a try.

  17. Jaan Naktin says:

    My first thought when I hear a complaint about an issue, large or small, is let us hear some data that shows we have a serious ID problem linked to gun shot wounds. I suspect there is paltry literature on the subject, so at a minimum I would hope that this blog post generates some meaningful research on the subject.

    I checked my hospital’s EPIC “slice and dice” feature. Of the 2.5 million “lives covered” a search for “gun shot wound” in the medical history revealed only 452 patients (.018%) of our patients have this unfortunate history. I cross searched osteomyelitis, decubitus ulcer and bacteremia and those searches hit for <10 each (the equivalent of an undetectable viral load). Granted my institution is a level one trauma center and as an ACO 2.5 million is a smallish slice of the total 12 million people in Pennsylvania.

    I also did a brief Google search on Scholar:

    Ordog, Gary J., Geron F. Sheppard, Jonathan S. Wasserberger, Subramanium Balasubramanium, and William C. Shoemaker. "Infection in minor gunshot wounds." The Journal of trauma 34, no. 3 (1993): 358-365.
    "The development of infection in minor gunshot wound injuries is an unusual occurrence when these injuries are limited to the soft tissue structures. Additionally, wound debridement and antibiotics are often unnecessary in minor uncomplicated gunshot wounds, but may be beneficial in patients who have sustained multiple injuries, gross wound contamination, significant tissue devitalization, large wounds, or delay in treatment."

    Not a lot of articles out there, but cross referencing the amount of gun shot wounds in my sphere of care with the incidence of infection in bullet trauma, I am not sure that the amount of disease represented therein constitutes a large subsection of my ID practice.

    Would be interested to hear what the numbers are at a larger urban center if anyone cares to share.

  18. raul davaro says:

    Great piece.
    A typical logical fallacy used by gun advocates is that guns make us safer.
    If that were the case, battlefields would be the safest place on earth.
    Another logical fallacy is that guns do not kill people, people kill people.
    The point is that without guns there is no gun violence, there may be knife violence, as they usually claim, but that is another topic.
    Lastly, I believe that the manufacture, sale and distribution of bullets should be highly regulated and those who participate in the trade, must be fingerprinted and registered.
    Remember, the constitution does not mention bullets.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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