Gun Violence: A Public Health Crisis

by Thomas P. Healy

During an early April violence prevention presentation for Public Health Week 2019, Brittany Yarnell, a surveillance epidemiologist at Marion County Public Health Department (MCPHD), shared data compiled from the Centers for Disease Control (CDC). The rate of probable gun-related calls per 100,000 emergency runs in Marion County has steadily increased from 2013 to 2017.

Guns killed seven people in Marion County the first weekend of April. Last year, 159 lives were lost to criminal gun violence. The tragic loss of life is grim evidence that gun violence is a crisis in Indianapolis.

The data include all Indianapolis Emergency Medical Services (IEMS) runs in Marion County, regardless of the victim’s county of residence, but do not include one important point: “Intent of the probable shooting is very rarely recorded in our datasets,” Yarnell said, “so we cannot separate out why they were shot—accidental discharge, legal intervention [police shooting], or malicious intent.”

Local public health advocates, first responders, elected officials, and neighborhood leaders are all in accord: Gun violence is not inevitable and can be prevented. How to accomplish that continues to be debated.

In 2011, the Indiana General Assembly passed legislation [PDF] that precludes local units of government from enacting gun control laws such as assault rifle bans, background checks, or waiting periods. That has encouraged cities like Indianapolis to pivot to a public health approach to gun violence prevention. In 2018 the City-County Council passed Resolution No. 81 [PDF] that declares gun violence and violent crime a public health danger. The Council pledged to prioritize funding initiatives and programs to reduce gun violence and violent crime and directed the Office of Public Health and Safety (OPHS) and MCPHD to “establish and operate programs and to seek funding appropriate to alleviate the public health danger.”

OPHS director Paul Babcock said that Mayor Joe Hogsett created the department to bring public health approaches to public safety issues such as gun violence. “What that means is, within the environment we operate in, how do we address the underlying causes?”

In 2016, OPHS worked with IMPD to establish behavioral health units (BHU) that include law enforcement officers as well as trained clinicians to respond to police runs and evaluate whether the individual(s) involved need mental health assistance. A year later, OPHS and IMPD formed mobile crisis assistance teams (MCAT) in partnership with Midtown Community Mental Health and IEMS. “That program was designed to address a situation in a needs-based manner and de-escalate it,” Babcock said.

After two months of in-depth training in subjects including addictions, mental health, homelessness, and veterans’ issues, MCAT team members are prepared to engage with residents in crisis and help prevent costly interaction between people in distress and emergency medical teams or the criminal justice system. BHU provides longer-term support that can include wraparound service referrals and follow-ups to ensure continuity of treatment. MCAT teams currently serve in North, East, Downtown, and Southeast IMPD districts.

Dr. Gregory Singleton, chief medical officer for Midtown Community Mental Health, said his staff provides IMPD with crisis intervention training—a two-hour class that teaches police officers skills to cope with mental health issues they encounter in the streets. “If they have reason to think a person may have a mental health concern, IMPD can call and have one of our crisis clinicians be at the scene to see if they can help out or intervene at that moment,” he said.


The American Public Health Association (APHA) recognizes that gun violence is contagious and advocates for a comprehensive public health approach [PDF], but that is stymied by a lack of data. APHA’s current president is retired Purdue University professor Pamela Aaltonen. “The focus of my presidency is on the evidence basis of public health,” she said by phone from her West Lafayette office. “One challenge we have with firearms violence is the Dickey Amendment, which prevents the CDC or other organizations from funding research.”

Enacted by Congress in 1996, the Dickey Amendment restricts CDC funds for injury prevention from being used to advocate or promote gun control. “It’s frustrating from my perspective to look at the number of injuries and deaths related to firearms and not apply good science to it,” Aaltonen said. “We want to be serious and thoughtful and scientific in our approach, but with insufficient research we don’t know what the most effective preventative strategies are.”

Midtown Mental Health’s Singleton agrees. “Any time that limitations are placed on research into causes and effects of any sort of potential public health concern, it’s bound to have an impact on our ability to learn what is effective treatment.”

Paul Babcock said OPHS is working on evidence-based programs. “It not only helps individuals but also helps us spend tax dollars effectively.” Resolution 81 quotes an estimate from Giffords Law Center to Prevent Gun Violence that Indiana’s cost of gun violence totals $4.4 billion, or $671 per resident each year.[PDF]

Babcock said that part of OPHS’s long-term approach is measuring fiscal impacts of a public health approach. “How much does it cost for a person who cycles through the system to spend the night in jail, then appear before a judge, [plus] the cost of a public defender, prosecutor, and case worker?” he said. OPHS seeks to develop programs that keep people out of jail and quantify how much money is saved by diversion. “The preliminary results are going well—95 percent of the people we encountered did not get arrested,” he said.

OPHS and the Indiana University Center for Health and Justice Research were recently awarded a $500,000 grant from the Houston-based nonprofit Arnold Ventures [PDF] for an 18-month study to analyze the effectiveness of the MCAT and BHU programs. “We really hope to be able to put some scientific rigor behind it,” Babcock said.

APHA’s Aaltonen is all in favor of that. “Indy has been leading the way in doing some of this first responder work,” she said. At a recent public health innovation summit in Philadelphia, Aaltonen said two criminal justice representatives talked about diversion programs: “Instead of putting young people in jail, provide support systems, which is very positive in terms of having more productive citizens, but also in reducing the cost in criminal justice systems,” she said.


Taking a thorough look at the public health consequences of firearm violence requires confronting its effects on children, said Denise A. Senter, director of mental health and clinical services at Reach For Youth, a Midtown-based nonprofit that focuses on mental health, prevention, and social justice services for children and youths ages 7 to 18.

“We see a lot of children and youths who express fear about attending school due to the aggressiveness of their peers, or anxiety around someone bringing a weapon to school,” she said in a statement. Senter’s colleague Aaron McBride, RFY’s director of prevention services, shared statistics from the Indiana Youth Institute’s Kids Count in Indiana 2017 Data Book: In 2015, 6.2% of Indiana high school students reported carrying a gun on at least one day in the past month. [PDF]

According to the CDC, childhood experiences, both positive and negative, have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. As such, early experiences are an important public health issue. Much of the foundational research in this area has been referred to as Adverse Childhood Experiences (ACEs). CDC graphic.

Families stressed about their child’s safety may experience a panic reaction, according to Senter. “We know from trauma research and working with families, that when one is in a heightened sense of alarm, how one thinks and responds to others changes.” This can influence interactions with first responders, too. “Police, firefighters, or EMS workers may find resistance from those they are seeking to help or rescue because the impact of violence results in a sense of alarm, fear, and mistrust.”

Senter added that reaction might also spread misplaced focus on mental health. “While the public perception may be that those who have mental health issues are primarily the ones committing gun violence, statistics point to a relatively low rate of those charged with gun violence being mentally ill.”

Gregory Singleton said it’s important to dispel the perception that there’s a link between mental illness and violence. “People with mental illness are no more likely to be violent than those without a mental health disorder,” he said. “We run the risk of unfairly stigmatizing people who are not violent at all. If anything, violence with regards to mental illness tends to be self-directed—suicide or self harm—or directed at someone close with whom they live, but most often against themselves.”

Aaltonen acknowledges conversations about firearms are difficult but points to successful public health efforts to reduce automobile accidents. “In the 1950s everybody got together, took a broad look at the issue, and re-engineered cars and roads to promote safety. Over time, motor vehicle accidents have declined,” she said.

According to the Giffords Law Center, one person is killed with a gun in Indiana every 10 hours. That’s why Mike Hayward, IEMS chief of operations, supports a public health approach to firearm violence. “In medical terms, we can treat the symptoms or treat the cause. Looking for root causes is the only way to have long-term impact on the problem we’re trying to fix.”

A version of this article appeared in the April/May 2019 issue of the magazine.

5/03/19 UPDATE: The U.S. House of Representatives’ Labor-HHS-Education fiscal 2020 funding bill introduced 4/29/19 proposes allocating $25 million to the CDC and $25 million to National Institutes of Health to research how to prevent firearm injury and death. Details.

12/20/19 UPDATE: President Trump signed the 2020 spending package that includes $25 million to be split between the Centers for Disease Control and Prevention and the National Institutes of Health to study gun violence. Details.

©Tom McCain

IMPD offers reminder of Indiana gun carry laws, gun safety tips ahead of NRA convention.

INDIANAPOLIS – In advance of the June 2019 NRA convention in Indianapolis, IMPD provided the following information for residents and attendees about Indiana’s gun carry laws as well as gun safety tips. In addition, prior to the event a legal bulletin was issued to all sworn IMPD officers with a reminder of the rights of those legally carrying firearms in Indiana.

Indiana gun laws:

  • Individuals must have an Indiana license to carry a handgun in public. The application process can be started on the Indiana State Police website:
  • Owners of private property have the right to determine whether firearms are permitted on that property.
  • The law does not distinguish between the open carry and concealed carry of firearms.
  • No license is required to carry a rifle or shotgun in public.

Gun safety tips:

  • Do not leave a firearm in an unoccupied vehicle. Store your firearms in a locked cabinet, safe, gun vault, or storage case when not in use, ensuring they are in a location inaccessible by children and cannot be handled by anyone without your permission. If you are carrying a firearm, secure it in a holster that covers the trigger and trigger guard.
  • Always keep the firearm’s muzzle pointed in a safe direction. A “safe direction” means the gun is pointed so that even if an accidental discharge occurred, it would not result in injury.
  • Firearms should be unloaded when not in use. Whenever you pick up a gun, such as when removing it from or returning it to storage, remember to point it in a safe direction and make sure it is unloaded. It is also recommended to use a gun lock when the firearm is not in use. This should not be a substitute for secure storage.