Special Report: Dean Megan Ranney Brings a Public Health Approach to the Country’s Gun Violence Epidemic

Whether during an interview for Yale Talk: Conversations with Peter Salovey in August, or a panel discussion at Yale Law School in September, Yale School of Public Health Dean, Dr. Megan L. Ranney, MD, is sharing her advocacy and research on firearm injury and prevention at Yale.

Ranney is recognized as an innovative leader who brings community-driven approaches to addressing longstanding and emerging public health problems. She is also an emergency physician, and it was over a decade ago, at the beginning of a weekend shift in an emergency department in Rhode Island, that the urgent need to address the issue of firearm injury and prevention became clear to her.

Ranney’s summer weekends were a busy, adrenaline-fueled time for emergency physicians and nurses. The crackle of the EMT radio announced that this weekend would be no different – a patient with a firearm injury was on his way to the emergency department. Ranney had treated many firearm injuries before, but as the EMTs wheeled the patient in, “All the air went out of the room,” Ranney remembered.

The young man on the EMT’s gurney had shot himself in the head with his parents’ gun. “There was nothing we could do,” Ranney said.

His death has had a lasting impact on her. She learned that suicide is the most common type of gun death in the United States. She also learned that the man’s death occurred because he not only had a moment of desperation, but he knew how to access his family’s gun. And she realized that his death, like those of so many other people who were seen in the ED after a gunshot wound, was preventable.

She also realized that the tools to apply a public health approach to the country’s epidemic of gun violence already existed.

“I'd done a fellowship specifically in injury prevention,” she said. “And it struck me as ridiculous, unconscionable, that we weren't applying these very standard public health methods to this problem that was filling my emergency department, certainly every weekend night and many weeknights as well.”

At Yale, there is “an enormous opportunity … to be one of the leaders in good, effective, impactful firearm injury prevention work,” said Ranney, the C.-E. A. Winslow Professor of Public Health. “There are not a lot of universities in the country that are taking this issue on in a rigorous and impactful way. And I think there is a very special role that this university can play and that I hope to usher forward here at Yale School of Public Health.”

Over the last decade, 55 to 60% of gun deaths each year have been gun suicides, a statistic that often surprises people in the U.S., Ranney said.

Her public health method addresses firearm injury as a public health issue rather than focusing on firearms themselves. She uses the term firearm injury deliberately because it is less politically fraught than gun violence. Over the years, she and her colleagues have partnered with gun owners, physicians, school nurses, law enforcement, and others, both to identify who is at risk of gun violence and to address the structural issues in communities that increase the chance of gun violence happening there.

“No one wants themselves or their loved one to die of a firearm injury. Let's start at that universal truth and think about how we can put solutions in place that are culturally relevant and acceptable,” Ranney said.

“Whether I’m talking about Native American populations that have a significantly higher rate of firearm-related intimate partner homicide and suicide, whether I'm talking about working with the youth in New Haven and Bridgeport, these young, predominantly Black and brown boys who are at higher risk of being shot, or whether I'm talking about working with rural, elderly white men who have some of the highest rates of firearm suicide in the country – we need to respect the culture and make sure that the interventions we're developing fit within people's ways of life.”

Since the shooting at Sandy Hook Elementary School in 2012, gun deaths have increased by 40% nationally. In 2020, firearm-related injuries surpassed motor vehicle crashes to become the leading cause of death among young people ages 1 to 19 years in the United States.

Firearm deaths among children and adolescents jumped nearly 30% between 2019 and 2020 – more than double the 13.5% increase in the general population. The increases were driven by a 33.4% overall rise in firearm homicides, which disproportionately affect young people, especially Black and brown boys and men who are about 20 times more likely to die of firearm homicide than white boys or men, Ranney said.

A recent panel discussion at Yale Law School addressed firearm injury and domestic violence, an issue before the U.S. Supreme Court. The 5th Circuit Court of Appeals recently struck down the federal law prohibiting possession of firearms by people subject to domestic violence protection orders, ruling that prohibiting abusers from possessing firearms is unconstitutional under the Second Amendment. The case, United States v. Rahimi, is scheduled for argument before the U.S. Supreme Court in November during the court’s October 2023-2024 term.

If the case is upheld, Ranney said it will be a public health call to action, as intimate partner violence is the leading cause of homicide death for women. She fears an influx of domestic violence firearm injuries will be seen in hospital emergency departments across the country.

Ranney’s public health approach acknowledges that the country will not get to a place where it has zero firearm injuries. However, she believes, it could get the country back to 10 years ago, when there were 40% fewer gun injuries and deaths, she said.

Ranney believes educating and engaging with communities across Connecticut and the country about firearm injury prevention while centering on the voices of survivors is essential to making real change in law and policy. Recently, a resident advisor joined YSPH to advocate and educate around this issue. Nelba Márquez-Greene is a licensed marriage and family therapist specializing in grief, loss, trauma, and their impact on individuals and systems. As one of two Activists in Residence at the school, Márquez-Greene will lead seminars, give talks pertaining to her work, and advise students on related topics including how to support survivors of gun violence. Márquez-Greene’s daughter, Ana Grace, was murdered at Sandy Hook School on December 14, 2012.

According to Ranney, central to public health is the idea that you must think on a larger scale – not just about the patient in front of you, but also about individual- and population-level risk factors, and how to modify and reduce them. As an example, she points to programs that were put in place to reduce car-crash injury and deaths.

Over the last 50 years, deaths due to car crashes have declined by almost 70%. This was achieved not by focusing exclusively on the car, or through legislation, but through “a suite of different research and interventions that have effectively decreased both the number of car crashes, and the severity or the likelihood of death,” Ranney said.

A similar public health approach can be applied to firearm injury and prevention by first measuring the problem, identifying risk and protective factors, and developing and evaluating interventions to reduce risk or mitigate the effects of exposure. “Then, when we figure out what works, we scale it,” she said.

Speed limits, airbags in cars, drunk driving laws, and enforcement of those laws contributed to the reduction of car crash deaths. Other programs educated young drivers about drunk driving, while hospitals taught new parents how to use a car seat to decrease infant car crash deaths.

“It was things like setting up trauma systems nationwide to help save those who were in a car crash, and of course, we redesigned cars and made them safer,” Ranney said.

Safer gun storage is one of the most important things that can be done to reduce the risk of firearm suicide and homicide, she said. “If your loved one has dementia and they own a firearm, you should have a conversation with them about maybe taking the firearm out of the house while you're having a conversation about whether it’s safe for them to continue to drive,” she said.

“If you have a child or a friend who's showing signs of depression or suicidality and they have access to a firearm, talk about ways to reduce their access for a bit. Most kids who shoot themselves or others do so with their family’s guns. Kids know where guns are stored.”

“We also need to address the issue of social isolation. When we’re separated from each other, we see firearm injury and death increase,” Ranney said.

While many mass shootings are connected to domestic violence, others are connected to firearm suicide. But because there has been very little research on gun violence, the U.S. lacks the most basic understanding of this public health issue, Ranney said.

From 1996 to 2020, there was virtually no federal funding for gun violence research from the National Institutes of Health or the Centers for Disease Control and Prevention. As a result, the U.S. is years behind in understanding the evidence behind how to stop firearm injuries before they happen. “We wouldn’t accept that for heart disease. We don’t accept it for HIV or cancer or COVID-19. We should not accept it for firearm injury and death,” Ranney said.

When she started doing this work as an emergency physician in the early to mid 2000s, she was told by mentors to not take on the issue because she would never get funding. “In the early days of my doing this, we could get all the researchers who were studying this issue literally in a room. It was a dozen of us,” she said. To help jumpstart the field, she created a small nonprofit called AFFIRM to organize researchers who had similar interests.

It took a social media post in 2018, telling physicians to “stay in their lane,” to rally people around the issue. “My organization, AFFIRM, responded, ‘This is very much our lane, and here are all the reasons that gun violence is a health problem,’” Ranney said.

Two years later, for the first time in 24 years, Congress appropriated money to the NIH and CDC to fund research into firearm injury prevention. It was, she said, a landmark moment.

Noticeable progress on the issue will happen when cultural norms change around what safe, responsible firearm ownership looks like. Everyone has a role to play. “We all need to stand up for public health,” Ranney said.