Growing up, Adam was a lot like other kids.
He had a huge imagination from an early age. He'd spend hours building his own worlds, one Lego block at a time. Then, he'd bring those worlds to life, creating stories that animated the pint-sized environments and the characters occupying them. People considered him an "excellent student and a thoughtful friend," cherished his good sense of humor, and noted his "conscientious" nature. One Christmas, Adam dumped out his savings to buy toys for needy children.
His challenges were also typical.
As a toddler, like millions of American kids, he faced language delays for which he received care through New Hampshire's early intervention system. As a preschooler, like millions of American kids, he displayed ritualistic behaviors and temper tantrums. Through elementary school, like millions of American kids, he struggled with self-worth -- at one point, writing "loser" and "ugly" on his fingers during a poetry project.
But things began to go awry after "The Big Book of Granny." In fifth grade, Adam co-authored a spiral-bound, purple-covered comic book in which the elderly protagonist goes on a shooting spree. In subsequent years, Adam's parents divorced, he came to hate birthdays and holidays, and, defeated by homework, he stopped regularly attending school.
Then, on a frosty Connecticut morning, Adam Lanza killed 20 children, six staff, and his mother before taking his own life.
Almost immediately, Sandy Hook -- a quaint New England town founded 80 years before the second Amendment was inked into existence -- became synonymous with America's firearms epidemic. And, the epidemic's cost on our nation's families.
"We gather here in memory of 20 beautiful children," President Obama said at a prayer vigil days after the tragedy, "...[who] lost their lives in a school that could have been any school in a quiet town full of good and decent people that could be any town in America."
A decade later, in another school in another quiet town, 19 more children lost their lives. Grief-stricken Americans learned more names: Uvalde, Robb Elementary, Salvador Ramos. The headline was simple: one national newspaper, in oversized typeface, printed just one word.
"AGAIN."
Guns' Destructive Impact on Families
As implied by the headline, Ramos' act -- heartbreaking as it was -- wasn't altogether surprising. In that sense, Ramos and Lanza were simultaneously exceptional and utterly not. Indeed, gun ownership in this country is one of the most ubiquitous social determinants of health.
There are about 60 million more guns than people in the U.S., and almost 4 in 10 American households possess firearms. In other words, every night, some 30 million kids like Ramos and Lanza eat dinner and snuggle into bed in the shadow of a gun -- nearly triple the number who live in poverty, 5-times those who are food insecure, and more than 20-times those who experience homelessness.
During COVID-19, the number of Americans living around guns only increased further: 5 million American households became new gun owners, and the number of firearm background checks -- a proxy for purchases -- have reached record rates. Amongst those millions were people like Payton Gendron, the 18-year-old who killed 10 in a Buffalo supermarket just days before Uvalde.
Few determinants are as profoundly impactful on American health. During the pandemic, the gun homicide rate reached its highest point in 25 years. Our youth have been particularly impacted: nearly 10,000 Americans under 25-years-old died due to firearms in 2020, as homicide and suicide rates are markedly higher in children with access to firearms. In 2017, years of life lost due to guns surpassed those lost to car accidents for the first time ever. Comparing data on gun-related deaths of children versus law enforcement officers in recent years, attending school has become almost as life-threatening as joining the police.
The effects, as described by the American Academy of Pediatrics (AAP), can be summed up in just one word: "destructive."
Doctors' Pivotal Role in Harm Reduction
Despite the carnage, it's been easier to get guns than infant formula in recent months, as Golden State Warriors shooting guard Damion Lee emphasized after Uvalde.
Take, for example, Ethan Crumbley, who killed four students in Oxford, Michigan in November 2021 after acquiring a handgun through his parents. Or take Ramos, who purchased a gun shortly after turning 18 and just days before the Uvalde attack. Yet, the National Rifle Association would still prefer that "self-important anti-gun doctors to stay in their lane."
Thankfully, organizations like the American College of Physicians (ACP) and the AAP have upheld the vital role that doctors must play in firearm harm reduction. Within this context, the AAP has urged individual doctors to "incorporate questions about the presence and availability of firearms into their patient history." Beyond screening alone, the ACP has stated that doctors have "an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society," including on safety measures like gun storage and trigger locks, in addition to broader measures such as referral to community-based or other social support systems following high-risk psychosocial screening.
However, many doctors still don't know where to start with families like the Crumbleys or the Ramoses. For example, in my field of pediatrics, research indicates that only about one-fifth of doctors ever receive formal didactics on having these conversations. Screening rates in other specialties like family medicine, emergency medicine, and internal medicine are similarly low.
It is imperative, in today's America, that training programs include firearm harm reduction in their practice-based pedagogy alongside motivational and psychosocial interviewing. In tandem, oversight bodies like the ACGME and the AAMC should insist that this education become standard.
Perhaps due to these training gaps, the conversations encouraged by the ACP and the AAP are still not the norm. In my field, studies have found that only one-third of pediatricians ask about firearm access during well child checks. In fact, pediatricians ask about guns less frequently than they do smoke alarms.
Just like monitoring growth curves, inquiring about sexual behaviors, and screening for depression, pediatricians need to standardize these conversations as part of the routine childhood visit. The same is true for adult providers who are regularly evaluating blood pressures, A1C's, and BMIs in routine check-ups.
Indeed, for families like the Lanzas -- or for Emilie's, or Noah's, and those of the other 18 children killed that New England morning -- they have never been more urgent.
Physicians' Critical Role in Healing
Physicians also have an essential role to play outside of what's explicitly written in the guidelines. That's because, beyond the tens of thousands of Americans now dying of guns every year, many more survive. And for these survivors, doctors must attend to their longer process of healing.
On the one hand, the scars of gun violence can manifest physically, as in the over 200 Americans who are treated every day for nonfatal firearm-related injuries.
On the other, they can manifest emotionally, as in the countless more -- like the innumerable kids, parents, teachers, and neighbors at Sandy Hook elementary and Marjory Stoneman Douglas High School -- who live on with the trauma of having borne witness. Physically whole, but wounded nonetheless.
Thus, while harm reduction is essential, it isn't enough for those who have already been impacted by the scourge of American guns. Physicians must step up to support these "silent victims" too -- not only by performing trauma-informed screening, but also by communicating with school districts, police, and first responders to ensure no one suffering with the invisible wounds of gun violence is overlooked. And, to refer them to mental health, social workers, or other supportive services to promote their long-term wellbeing.
The late Paul Farmer wrote, "to those in great need, solidarity without the pragmatic component can seem like so much abstract piety." Instead, he said, to make a difference, sympathy amid tragedy must be accompanied by action.
In a moment where the "agains" keep coming, we don't have a moment to lose.
Eli Cahan, MD, MS, is a pediatrician at UCSF and an investigative journalist whose work has appeared in The Washington Post, LA Times, Rolling Stone, The Guardian, VICE, and elsewhere.