A recent advisory from the Surgeon General’s office is a missed opportunity to advance life-saving criminal justice interventions
The U.S. Surgeon General, also known as the “nation’s doctor,” provides Americans with the best available scientific evidence to improve their health and reduce their risk of illness and injury. In late June 2024, the Office of the U.S. Surgeon General released its first advisory that affirmed gun violence as a public health crisis. The landmark advisory reports detailed information on the scope and nature of gun violence in the U.S. and presents selected evidence-informed recommendations on prevention strategies.
The advisory release was lauded by leaders of the nation’s most influential medical organizations and widely covered by the media, including a story in the New York Times.
Unfortunately, the Surgeon General’s advisory falls short of its mandate to provide the best available scientific evidence. The advisory omits key research on underlying dynamics that generate the bulk of interpersonal gun violence in American cities — namely, violent disputes among high-risk individuals involved in gangs, robbery crews and drug-selling organizations that cause shootings in specific places. It also ignores rigorous program evaluations on effective criminal justice actions that save lives by focusing on high-risk people and places.
In his treatise “Of the Epidemics,” ancient Greek philosopher and physician Hippocrates advanced the “do no harm” ideal. Omitting key information from a high-profile national report contributes to continued harm in our cities by keeping policymakers, practitioners and community members in the dark on effective gun violence reduction strategies.
The nature of interpersonal gun violence in U.S. cities
The Surgeon General’s advisory notes that gun homicides are notably higher in urban areas and laments the long-standing disparate impacts of gun homicides on Black Americans. Concentrated poverty, segregation, systemic racism and other structural factors influence persistent shootings in Black communities in U.S. cities. In 2022, 60% of all gun homicide victims were Black, and the firearm homicide rate per 100,000 for males aged 18–34 was 110.6 for Blacks, 18.9 for Hispanics, and only 4.8 for whites. The racial disparities in homicide rates are so large that it adds nearly three years to the Black-white life expectancy gap.
Reducing gun violence in Black communities is clearly a matter of social justice. As such, it is peculiar that the Surgeon General’s advisory did not take a closer look at the underlying dynamics associated with these glaring disparities.
It is well known in criminology and public health circles that gun violence in U.S. cities is highly concentrated in a small number of high-risk places and committed by and against a small number of high-risk people. For example, between 1980 and 2008, fatal and nonfatal shooting trends in Boston were mostly generated by recurring incidents at less than 5% of the city’s street segments and intersections that accounted for 74% of total shootings during this 29-year period. Almost 90% of street segments and intersections in Boston never experienced a single shooting incident during the study period and more than 1,000 shootings occurred at only 60 very high-risk street segments and intersections. Public housing buildings, gang turfs and street drug markets were persistent shooting hot spots in Boston.
Omitting key information from a high-profile national report contributes to continued harm in our cities by keeping policymakers, practitioners and community members in the dark on effective gun violence reduction strategies.
High-rate offenders who are members of gangs, robbery crews, drug-selling organizations and other high-risk co-offending networks are often the perpetrators and targets of shootings in U.S. cities. On average, more than half of a city’s homicides are generated by these criminally active groups that represent less than 1% of a city’s population. In some cities, group-on-group retaliatory violence drives the prevalence of shootings. For instance, while a co-offending network of 763 individuals connected to 10 gangs represented less than 3% of one Boston neighborhood’s population, their ongoing conflicts generated 85% of the shootings in that neighborhood.
Illegal guns are prevalent in these violent social networks. Gang members, convicted felons and other high-risk individuals tend to access firearms through theft and from traffickers, including straw purchasers, unregulated private sellers and corrupt licensed dealers. The Surgeon General’s advisory makes no mention of these criminal sources of firearms.
Criminal justice should be an explicit part of the U.S.’s public health approach
The Centers for Disease Control and Prevention (CDC) defines a public health approach to violence prevention as drawing on a multidisciplinary base of scientific evidence.The CDC further emphasizes that input and collective action is needed from diverse public and private sectors, including the justice system, to address complex violence problems. It identifies a public health approach as following a general four step scientific model: 1) defining and monitoring the problem, 2) identifying risk and protective factors, 3) developing and testing prevention strategies, and 4) assuring widespread adoption of effective strategies. The same action research model is used to support the development of prevention programs in many social science disciplines, including for problem-oriented policing and situational crime prevention efforts. Given this common ground, blending public health and criminal justice approaches should be straightforward.
The Surgeon General’s advisory suggests that a public health approach is complementary to the work of law enforcement to hold perpetrators accountable. This one-dimensional statement is the only direct acknowledgment of criminal justice intervention in the advisory. There are some indirect suggestions that the justice system is relevant to gun violence prevention, including the role of the court in implementing extreme risk protection orders (sometimes called “red flag” laws) that temporarily restrict potentially dangerous people from possessing firearms. The advisory also relies on the unspoken need to have police and prosecutors enforce the numerous new laws proposed in it. While delivering justice to victims and their loved ones is indeed a critical function, the report ignores the preventive power of the criminal justice system to reduce gun violence through deterrence, incapacitation and crime opportunity reduction.
The Surgeon General suggests that gun violence in marginalized communities can be reduced by addressing structural determinants through investments in housing, enhancing access to high-quality education and health care and improving economic opportunities. These are laudable goals that Americans should support. However, these long-term strategies will not bring immediate relief to neighborhoods suffering from ongoing shootings. And, unfortunately, the endorsed short-term community violence interventions may not provide much relief either. Program evaluations of street outreach programs that use credible messengers to interrupt violence and provide services to gangs and other high-risk individuals suggest mixed effects. Very little is known about the efficacy of hospital-based violence intervention programs.
While some public health researchers acknowledge the efficacy of criminal justice interventions in reducing gun violence, the prevailing orientation of medical and public health is to ignore criminal dynamics driving recurring shootings at specific places and downplay the potential for police, prosecutors and correction officials to play a meaningful role in halting violence. This is particularly vexing given that the public health model is supposed to be comprehensive and other public health campaigns, such as against drunk driving, have explicitly included criminal justice agencies and law enforcement actions. Evidence-informed criminal justice strategies to reduce gun violence include modifying crime opportunities at hot spots, using focused deterrence to change violent gun behaviors, preventing unlawful and unnecessary police-involved shootings, improving shooting clearance rates and shutting down illegal gun markets. These kinds of strategies should be included as part of a public health platform.
The prevailing orientation of medical and public health ignores criminal dynamics driving recurring shootings at specific places and downplays the potential for police, prosecutors and correction officials to play a meaningful role in halting violence.
Public health resistance to engaging criminal justice agencies seems to stem from well-considered concerns over racial justice and equity in the criminal justice system. Pernicious problems, such as police violence and abuse, unfair prosecutions and sentencing and resistance to accountability make it difficult to see how criminal justice actions contribute to public safety. Rather than avoiding these conversations, public health practitioners and researchers should be at the forefront of harm reduction collaborations by blending criminal justice reform efforts with violence reduction strategies. Given their training and analytic expertise, public health researchers and practitioners have much to offer criminal justice agencies in diagnosing and addressing unintended consequences of law enforcement actions. In future public health advisories, the risk of harm associated with a particular criminal justice strategy could be explicitly noted, and recommendations on how to minimize harm through engaging communities, embracing accountability, ensuring adequate supervision and requiring training in lawful and procedurally justice actions should be made.
A concluding thought
Ignoring scientific evidence is a great concern as it leads to unfocused and ineffective responses to underlying conditions that cause gun violence problems to persist. Excluding violence prevention partners with a proven track record for making neighborhoods safer is contrary to our government’s stated public health ideals. If small populations of high-risk people and high-risk places are not properly managed by government agencies and their nonprofit and community partners, rapid and steep increases in gun violence can occur with the potential to diffuse to other areas of cities. Other researchers have made similar critiques of the limits of current public health portfolios. It is high time for the medical and public health profession to embrace a broader evidence base on the nature of urban gun violence in order to take a truly comprehensive approach to their prevention efforts.