An essay published AMA Journal of Ethics supported the implementation of hospital-based violence intervention (HBVI) programs to reduce the growing burden of trauma care in the United States. In 2010, the cost of firearm injuries alone was cited at $174.1 billion; beyond that, the ensuing “pain, disability, lost productivity, grief, fear, and demoralization” emphasize the growing impact of violence on trauma systems and the population at large.

Per the conception of an “ideal trauma system” recognized by the American College of Surgeons Committee on Trauma, optimal care includes both acute rehabilitation and injury prevention.

In a process termed “trauma recidivism,” those who experience an initial violent injury are at significantly elevated risk for serious recurrent injury or death. Modern trauma systems, the authors argued, have been insufficient in addressing the “social underpinnings” of violence, with trauma recidivism levels recorded as high as 44% in some urban areas.

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HBVI programs emphasize the social determinants of health, leveraging access to counseling and case management at the time of injury, which for many patients represent the only access point to healthcare. In providing community resources such as housing or legal advocacy, HBVI programs can prevent trauma from recurring.

Single-institution implementation studies on HBVI have indeed indicated significant reductions in trauma recidivism, healthcare expenses, and patient mortality. However, most hospitals have yet to adopt these strategies, citing the necessity of first obtaining high-quality evidence of their efficacy.

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The authors argue, however, that such assessments will be difficult; collecting accurate longitudinal data is challenging in populations most affected by interpersonal violence given high mortality rates, limited access to health care, and intersections with the criminal justice system. The authors instead advocate for the implementation of preventive measures as soon as possible to combat the growing incidence of gun violence.

Trauma surgeons “have a professional responsibility…to prevent injuries,” the authors concluded, arguing that harm reduction for violence should begin at trauma care centers during first contact. As violence in the United States escalates, the authors cited the “professional and moral responsibility” of medical systems to reduce trauma recurrence, which could be accomplished through the implementation of HBVI programs. 


Scarlet S, Rogers SO Jr. What is the institutional duty of trauma systems to respond to gun violence? AMA J Ethics. 2018;20(5):483-491.