JAMA Summit on Reducing Firearm Violence

 

One of my frequent topics on this blog is firearm violence, the likely causes, and ways to prevent it.    When I saw this topic in my most recent edition of the Journal of the American Medical Association (JAMA) – I could not wait to read it.  Now that I have - it is a different story.  

The paper begins by posting some astonishing numbers of gun violence in the United States.  Since the year 2000, there have been 800,000 firearm deaths and 2 million firearm injuries in the US.  Firearms are the leading cause of death in children in the United States.  There were no references to school or mass shootings even though the United States is the only high-income country with this problem.  No other country comes close.

There is a description of the group who produced this paper.  We learn that it consisted of a multidisciplinary group of 60 thought leaders and they were charged with producing an innovation roadmap to decrease firearms harms by 2040. Their recommendations are summarized in this 12-page document and I do not think it will prove very useful. 

The best part of the document is the table Evidence Base for Interventions That Demonstrate Significant Reductions in Firearm Violence.  For 20 years, the Dickey Amendment restricted research on firearm violence and the prevention of firearm violence largely done by the CDC and NIH.  Starting in 2020 funding for research on firearm violence was resumed at both agencies.  This July, the Trump administration cut $158M in gun violence prevention grants (69 of 145 community violence intervention (CVI) grants.   In October, the Trump administration fired key personnel in the CDC violence prevention program that collected data and produced dashboards based on that data.   They also closed the White House Office of Gun Violence Prevention that had been initiated under the Biden administration.  Despite that active suppression of gun violence research except for the last few years – several effective interventions have been discovered and they are included in the table.  They cut across areas involving licensing, violence prevention programs, disarming potentially violent offenders, changing the violence ecosystem, improving the socioeconomic environment, decreasing the availability of alcohol, and an increased police presence and more efficient and targeted policing.

When I think about the people who told me they were saved by their inability to purchase firearms it generally came down to legal waiting periods and federal firearms checks.  They were people considering firearm violence directed at themselves or another person and the only reason it did not happen was that they were prohibited from purchasing a gun at that instant.  In retrospect they were universally thankful that they could not get the gun and when the impulse passed, they did not purchase one later.  This document does not specially mention either of those interventions.

Despite the table, the document focused on a lot of speculative interventions looking at reducing community violence, improving the socioeconomic status, and changing the ecology of neighborhoods where these kinds of crimes occur.  I have no doubt these strategies will be useful to some degree but cannot help but see that most people in these communities are law abiding and are an unlikely source of gun violence.  That does not mean they are immune to the effects of gun violence because just having a gun in the house increases the chances of gun violence death by suicide or accident.

Treating guns as a commercial product is a suggested strategy.  The argument suggests that manufacturers and sellers assume product liability.  When that happens liability suits or the threat of these suits will change gun manufacturers to make safer products.  They provide examples of successful lawsuits.  We should all take a lesson from mental health care in considering a strategy that depends on civil liability.  The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was supposed to lead to equal treatment of mental illnesses.  It treats insurance coverage as a commercial product.  It has led to lawsuits that (while successful) have had absolutely no impact on the insurance industry.  Their attitude is “if you think you are being treated unfairly – you will have to sue us and win.”   Their basic rationing practices remain unchanged.

There are frequent mentions of technology and artificial intelligence (AI) in the report.  Smart guns that can only be fired by the owner have been talked about for quite some time – but there are not a lot of products. Analyzing data by AI, even if it appropriately designed to incorporate racial diversity and equity does not seem to be a major innovation. The current data being collected lacks the granularity (see below) to properly study the decision making involved.

The authors make the argument that people seem to ignore the fact that violent crime is significantly decreased over the past decades.  They do not describe how this happens but suggest that countering this fallacy is important. It is a difficult fallacy to counter when a major political party uses this narrative daily to rationalize laws that promote gun extremism and gun permissiveness.  Politics is not mentioned at all in the document even though one political party would find it difficult to function without repeated references to gun access and promoting gun extremism.

What is missing?  Just about everything I have written about on this blog.  First, guns are a problem and there is no way around it.  I was concerned to see the following sentence in this paper:

“Firearms are not a cause of violence but, because of their high lethality and ability to injure large numbers of people, result in serious harm when combined with violent acts.”

It contrasts with:

“Primordial prevention addresses the most upstream, root-level causes of adverse outcomes—well before they take shape—by changing the structures and systems that give rise to them. This means transforming the fundamental social, environmental, and economic contexts that foster violence. This upstream approach is relevant to all types of firearm harms and applies across urban and rural settings. The current moment demands bold, systems-level interventions that prioritize housing stability, economic opportunity, environmental improvement, and equitable policies.”

In biological systems theory, a firearm is not conceptualized in isolation as an inert object.  Firing a gun is seen as an emergent property of the interaction of multiple subsystems in the individual, the task, the implement used, and the environment.  There are many examples.  You are not brushing your teeth without a toothbrush or walking with a cane without the cane.  The firearm is an integrated component of that system.  To prevent adverse outcomes from that system, all the components including the gun need to be addressed.  It is guns and people that account for the outcome not either in isolation.

Second, there is not a single mention of culture as a significant factor. There is discussion of changing narratives and all the various groups involved but not a single mention of the cultural aspects of gun violence. More specifically there is no mention of how the US has gone from a culture of firearms for hunting and target shooting in the mid-20^th century to the current culture of carrying firearms with minimal regulation like what existed in the mid-19^th century.  That was before towns in the Old West passed ordinances about not carrying firearms in town.  There is clear current evidence that lax firearm regulation correlates with firearm casualties and deaths.

Third, there is a clear gun extremism culture that I have elucidated in this past post.  The elements are clear and this level of gun extremism correlates with increases in mass shootings and school shootings.  Gun extremists typically take and expansionist view of the Second Amendment while ignoring the preamble.  Many are also strict constructionists who ignore gun restrictions that were in place when it was written. 

Politics is a clear factor in gun extremism since it is promoted by the politicians, judges, and operatives of one political party.  It is really a combination of gun extremism and inaction. After every mass or school shooting – nothing ever gets done.  School shooters are a subset of the gun extremist culture and a clear example of how cultural effects can spread to other people.  At the broader political level gun extremism is heritable and passed on from generation to generation.

Fourth, the neuroscience of human decision making and development is ignored, especially the emotional component.  It has been known for some time that human decision making is more than a purely rational process and that an emotional component is essential (5-8).  Since then, the neurobiological substrate has been partially elucidated but research continues to find new components (9).  The basic observation seen on any true crime TV show – the relationship of anger and gun availability to gun violence has not been adequately investigated.  The epidemiological methods use to examine gun violence gather adequate contextual details for accidental injury and death but not homicide (10).  One of the gun extremist myths is that gun owners and carriers have superior ability to control themselves and avoid making mistakes. There is no reason to expect that is true.  Just having more people carrying lethal weapons in public will increase the chances of a violent confrontation.      

Fifth, the authors recommend strategies to decrease alcohol consumption and there is some evidence that younger generations are consuming less alcohol.  At the same time, we have increased cultural permissiveness for other intoxicants that are as likely to be associated (directly or indirectly) with aggression and violence – specifically stimulants, cannabis and cannabis derivatives, synthetic cannabinoids, and opioids.

Sixth, homicide prevention needs to have a similar path toward resolution that suicide prevention currently has.   To put things into perspective, many people with either problem end up on psychiatric units in hospitals.  Most of them are there because of stated suicidal ideation or making a suicide attempt.  The violent people are typically there because of police calls where they had to contain an aggressive person who has a mental illness.  There are no hot lines comparable to suicide hot lines.  There are no homicide prevention programs for the acutely homicidal person. As far as I know there has been no research in this area.  Aggressive and homicidal behavior needs to be identified as a clinical and public health problem that needs to be addressed in a timely manner. 

These are some obvious unaddressed factors in this report.  It is probably easier to consider general solutions than more specific cultural and political ones.  But we can no longer pretend that maintaining and ignoring these cultural factors will lead to any effective changes.  It also requires adequate expertise in data collection, sociocultural changes, and in clinical settings. More discussion in this area will result in people who are more comfortable talking about the problem.   This is a complex problem but it does have solutions.  Considering the biological and sociocultural factors described – it should be apparent that the sociocultural factors are primary. The current administration is doing nothing to address childhood adversity.  The logical place for intervention is changing the sociocultural environment with legal and public health interventions.  It will take more than what is  suggested in this review.   

George Dawson, MD, DFAPA

 

References:

1:  Rivara FP, Richmond TS, Hargarten S, Branas CC, Rowhani-Rahbar A, Webster D, Richardson J Jr, Ayanian JZ, Boggan D, Braga AA, Buggs SAL, Cerdá M, Chen F, Chitkara A, Christakis DA, Crifasi C, Dawson L, deRoon-Cassini TA, Dicker R, Erete S, Galea S, Hemenway D, La Vigne N, Levine AS, Ludwig J, Maani N, McCarthy RL, Patton DU, Quick JD, Ranney ML, Rimanyi E, Ross JS, Sakran JV, Sampson RJ, Song Z, Tucker J, Ulrich MR, Vargas L, Wilcox RB Jr, Wilson N, Zimmerman MA; JAMA Summit on Reducing Firearm Violence and Harms. Toward a Safer World by 2040: The JAMA Summit Report on Reducing Firearm Violence and Harms. JAMA. 2025 Nov 3. doi: 10.1001/jama.2025.18076. Epub ahead of print. PMID: 41182880.

2:  Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450.

3:  Lin JC, Chang C, McCarthy MS, Baker-Butler A, Tong G, Ranney ML. Trends in Firearm Injury Prevention Research Funding, Clinical Trials, and Publications in the US, 1985-2022. JAMA Surg. 2024;159(4):461–463. doi:10.1001/jamasurg.2023.7461

4:  Zaller N, Brown J, Fischer K, Abaya R, Cardoso LF, Dreier FL. The Critical Role Of Federal Funding In Combating Firearm Violence. Health Affairs Forefront. 2025.  Accessed on November 8, 2025) https://www.healthaffairs.org/content/forefront/critical-role-federal-funding-combating-firearm-violence-public-health-perspective

5:  Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cereb Cortex. 2000 Mar;10(3):295-307. doi: 10.1093/cercor/10.3.295. PMID: 10731224.

6:  Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cogn. 2004 Jun;55(1):30-40. doi: 10.1016/j.bandc.2003.04.001. PMID: 15134841.

7:  Sanchez EO, Bangasser DA. The effects of early life stress on impulsivity. Neurosci Biobehav Rev. 2022 Jun;137:104638. doi: 10.1016/j.neubiorev.2022.104638. Epub 2022 Mar 24. PMID: 35341796; PMCID: PMC9119952.

8:  Potegal M, Stemmler G. Constructing a neurology of anger. In International handbook of anger: Constituent and concomitant biological, psychological, and social processes 2009 Dec 21 (pp. 39-59). New York, NY: Springer New York.

9: Jung J, You IJ, Shin S. Thalamo-hippocampal pathway determines aggression and self-harm. Sci Adv. 2025 Nov 7;11(45):eady5540. doi: 10.1126/sciadv.ady5540. Epub 2025 Nov 5. PMID: 41191756; PMCID: PMC12588284.

10:  Forsberg K. Surveillance for Violent Deaths—National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022. MMWR. Surveillance Summaries. 2025;74. https://www.cdc.gov/mmwr/volumes/74/ss/pdfs/ss7405a1-H.pdf

Graphic:  The graphic above is a line drawing of my MRI.  I intend to place it in a larger drawing of all the relevant factors to consider when it comes to gun violence. That is a work in progress and it is an extremely complex drawing.  When I complete it – I will replace the graphic at the top of this post.