RPA-Essay #6 - See attached. thank you.

Salma M. Abdalla, MBBS, MPH, Boston University School of Public Health, \ Epidemiology Department, Boston, MA 02118, USA.

Email: abdallas@ bu. edu Commentary Public Health Reports 2021, Vol. 136(1) 6-9 © 2020, Association of Schools and Programs of Public HealthAll rights reserved.

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sagepub. com/ journals- permissions DOI: 10. 1177/ 0033 3549 20965263 journals. sagepub. com/ home/ phr A Public Health Approach to Tackling the Role of Culture in Shaping the Gun Violence Epidemic in the United States Salma M. Abdalla, MBBS, MPH 1 ; Katherine M. Keyes, PhD, MPH 2; and Sandro Galea, DrPH, MD 3 Gun- related violence is a leading cause of morbidity and mortality in the United States. In 2016, more than 37 000 firearm-­related­ deaths­occurred­ in­the­ country. 1 Furthermore,­ 2­or­ 3­firearm-­related­ injuries­occur­for­ every­ firearm-­related­ death. 2 The burden gun violence poses for the health of the population is disproportion- ately larger than it is in many countries. About 35% of global­ firearm-­related­ suicides­occur­in­the­ United­ States­ and,­ compared­ with­other­ high-­income­ countries,­firearm-­ related homicide rates are 25 times higher in the United States. 1,3 Increasing evidence links high rates of gun violence to the ubiquity of guns, high rates of firearm ownership, and low barriers to accessing firearms in the United States. 4-9 Several high- income countries have reduced firearm- related violence through interventions that reduced the availability of guns. For example, after a mass shooting tragedy in 1996, the government of Australia carried out a national reform that restricted ownership of legal fire- arms, established a firearm registry, and implemented a permit requirement for new purchases, among other mea- sures. 10,11 In 2014, a total of 32 firearm- related killings occurred in Australia, marking a 63% decline from 1990. 12 Similar policies are implemented in Canada, Norway, the United Kingdom, New Zealand, and other countries. 13 Conversely, the United States does not have a robust federal­ approach­ to­limit­ the­availability­ of­firearms. ­ Moreover, states vary widely in the laws enacted to regu- late­ the­sale­ of­firearms,­ background­ checks,­and­prevent- ing­ children’s­ access­to­firearms.­ For­example,­ the­federal ­ law that requires background checks has several loopholes (eg,­ allowing­ gun­dealers­ to­sell­ firearms­ without­a­back- ground check if the Federal Bureau of Investigation does not complete the background check in 3 days), and only 6 states require safety training for people interested in pur - chasing­ a­firearm. 6 People in the United States own about half­ of­the­ firearms­ designated­ for­civilian­ use­in­the­ world, ­ which is, in part, indicative of the broad availability of, and permissive access to, guns. 14 Culture and the Resistance to Tackle Gun Violence in the United States Given the heavy price the United States pays for its wide- spread availability of guns and the evidence that limiting availability­ can­reduce­ firearm-­related­ violence,­it­seems­ rea- sonable to ask: Why is there resistance to limit the availabil - ity of guns on a national level? Federal laws i have not changed drastically to restrict access­ to­firearms­ despite­mounting­ evidence­supporting­ the­ importance of gun control and as tragic, highly publicized, incidents involving gun violence continue to befall the United States. Even mass shootings at schools and churches—such as in Sandy Hook, New Jersey, and Charleston, South Carolina—did not create enough momen - tum to trigger a substantive federal legislative overhaul. A­wide­ range­ of­factors,­ including­ commercial­ influences,­ contribute­ to­the­ current­ state­of­affairs­ and­create­ a­set­ of­ circumstances­ that­are­simply­ different­ than­that­of­other­ high- income countries. Central to these factors, the role cul- ture plays in maintaining the gun status quo in the United States is receiving increasing attention in the sphere of aca - demic public health. 2,15,16 Culture is a complex concept that encompasses many areas. In 1871, anthropologist Edward Taylor­ defined­ culture­as­“that­ complex­ whole­which­includes­ knowledge, belief, art, law, morals, custom, and any other capabilities and habits acquired by man as a member of soci- ety.” 17-19 The meaning of culture is often contested and depends on the discipline, which indicates the need for a Abdalla et al7 multidisciplinary understanding to determine the role of cul- ture in shaping the epidemic of gun violence . Scholars from several disciplines have explained how com- plex­ social­ (eg,­individualism­ as­the­ defining­ characteristic­ of­ the country), legal (the second amendment, federal structure, and lobbying laws), and historical (eg, slavery and racism) fac- tors have interacted to create a gun culture that favors individ- ual rights over gun control. 20-28 For example, one study found that­ cultural­ views,­rather­than­scientific­ arguments­ or­facts, ­ shape political positions on gun control among people living in the United States. 29 Public health scholars have also attempted to quantify gun culture. One analysis found that identifying with a social gun culture was associated with a 2.25 times greater likeli - hood of gun ownership compared with not identifying with a social gun culture. 30 However, public health scholarship has lagged­ behind­ in­efforts­ to­understand­ gun­culture,­ which­ may guide public health action on the gun violence epidemic.

This paucity of scholarship concerning gun culture stands in contrast to other health outcomes such as alcohol, in which public health scholarship has focused on the intersection of alcohol policy and drinking culture to formulate recommen - dations to reduce alcohol- related harm. 31 The comparatively absent literature in public health on gun culture is under - standable. Although culture is indubitably a foundational determinant of health—it shapes where we live, eat, play, and­ grow—it­ is­difficult­ to­measure­ the­effects­ of­culture­ on­ the­ health­ of­populations­ and­even­ more­ difficult­ to­intervene­ to change a culture that undermines the public’s health. 32-34 What, therefore, might be a reasonable public health approach to tackling gun culture to mitigate the gun violence epidemic in the United States? A Public Health Approach to Changing Gun Culture Changing gun culture seems to be a necessary element of tackling the epidemic of gun violence in the United States.

Changing gun culture will require creating a new narrative that frames gun violence as a public health issue and high- lights the consequences of gun violence on population health.

Shifting popular opinion on a prevailing cultural preference has contributed meaningfully to reducing harm in the case of other­ adverse­ influences­ on­health.­ Until­the­1960s,­ up­to­ 75%­ of­driving-­related­ injuries­and­deaths­ were­attributed­ to­ driving­ while­under­ the­influence ­of­ alcohol. 35 The predomi - nant narrative at the time was that these deaths were largely unavoidable consequences of accidents, and laws against driving­ under­the­influence­ were­rarely­ implemented.­ Consumer­ advocacy­and­grassroots­ mobilization­ efforts,­ which­ formalized­ and­amplified­ the­voices­ of­victims­ and­ their families, rallied resources to mount campaigns for cul- ture change. Advocate groups such as Mothers Against Drunk­ Driving­ contributed­ to­legislative­ efforts­for­safe­ road­ use, often persisting against pushback from lawmakers and the public. 36,37 Another example is the movement to reframe the national conversation on smoking. For years, smoking was viewed as an individual behavior, a habit for millions, and it was romanticized­ in­films­ and­in­advertisements.­ Outcries­against­ smoking in the 1960s and 1970s were opposed by a well- connected­ and­well-­financed­ industry.­However,­ this­social­ movement helped advance antismoking policies by high- lighting the adverse health outcomes associated with smok- ing and the rights of nonsmokers. 38 With these examples in mind, we propose 4 avenues that may be useful to public health­in­its­efforts­to­tackle­the­gun­violence­crisis. First, taking a multidisciplinary approach to the crisis of gun violence can help us identify the appropriate actions needed to push against a deeply entrenched gun culture.

Multiple social sciences disciplines, such as sociology and anthropology, have grappled with the meaning and implica - tions of culture for a long time. These disciplines are equipped with the theoretical and methodologic tools to study gun culture and are indispensable partners to public health on this front. Taking a multidisciplinary approach also suggests that tackling gun violence will require addressing the­ root­ causes­ of­gun­ culture,­ such­as­racism,­ which­affects­ almost all aspects of life in the United States. For example, the racial turmoil of the 1960s and 1970s fueled talks of gun control. It was then that special interest groups capitalized on the moment to promote discussions on gun rights as an important element of the national identity. Gun manufactur - ers­ used­ this­moment­ to­promote ­a­ narrative­ concerning­ “the­ urgent need to protect gun rights” as a means to promote sales. 39 Second, public health has little choice but to engage the media to frame the discussion on gun violence as a public health emergency rather than a political debate. This framing can, in part, be accomplished by collaborating with the media to present gun violence research to a broad audience. The democratization of media through digital means provides a potential avenue to cultural change that was unavailable in previous decades. In 2018, emergency medicine physicians mobilized the power of both storytelling and social media (Twitter) by sharing their daily experiences of treating patients­ suffering­ from­the­tragic­ consequences­ of­gun­ vio- lence. 40 The mobilization was organic—like many other efforts­ by­community­ members­working­to­improve­ the­ health­ of­populations.­ However,­it­is­ difficult­ to­change­ cul- ture­ by­solely­ relying­ on­such­ spontaneous­ efforts. 41 Changing culture will require more deliberate and sustained campaigns to continuously highlight the human cost of gun violence,­ as­was­ done­ as­part­ of­the­ larger­ advocacy­ efforts­to­ reduce alcohol- involved driving. 42,43 A third approach requires engaging allies with similar goals.

Movements such as the March for Our Lives have the potential to push the conversation in the right direction. After a shooting at­ the­ Marjory­ Stoneman­ Douglas­High­School­ in­Parkland, ­ Public Health Reports 136(1) 8 Florida, students organized a protest of about 800 000 people in Washington, DC—not counting the other smaller protests in multiple cities—calling for stricter gun control legislation. 44 Concerted progress will require collaborating with such move- ments to advance the narrative of gun violence as a public health emergency. Other potential allies can be movements with values that align with the goal of tackling the gun violence epidemic (eg, the Against Suicide Movement) and institutions that shape culture in the United States, such as churches and even movie production companies. Fourth, although shifts in culture can lead to a change in policy, a policy overhaul can sometimes precede a cultural shift. 45 For example, shall issue laws in numerous states— which­ allowed­ people­to­walk­ around­ with­firearms­ on­their­ bodies—helped­ further­the­narrative­ that­firearms­ are­an­ acceptable­ everyday­cultural­object­in­the­ United­ States. 21 The opposite can be true. At the time of implementing gun- control­ policies, ­Australia­ had­a­high­ rate­of­firearm­ owner- ship. Yet, changing the laws was then followed by changes in public views. One factor that helped push gun law reform forward was the commitment of a newly elected Australian prime minister who was willing to use his political capital to create a large coalition of advocates for gun control. 10 The role­ of­key­ political­ actors­in­occasioning­ inflections­in­cul- ture­ holds­ an­important­ lesson­for­efforts­ aimed­at­changing­ gun culture in the United States. Conclusion The United States has a unique gun culture that is driven by a wide range of legal, historic, and societal factors. Tackling the gun violence epidemic requires taking gun culture into account. Shifting the narrative concerning guns will require engaging other disciplines, harnessing the power of social media and storytelling, collaborating with powerful allies, and urging for gun control legislation that may precede a cul- tural change.

Declaration of Conflicting Interests The­ authors­ declared­ no­potential­ conflicts­of­interest­ with­respect­ to the research, authorship, and/or publication of this article.

Funding The­ authors­ received­ no­financial­ support­for­the­ research,­ authorship, and/or publication of this article.

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