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Canadian Doctors for Protection from Guns: how physicians contributed to policy change
  1. Joshua S Ng-Kamstra1,
  2. Jason Lajoie2
  1. 1 Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
  2. 2 Department of English Language and Literature, University of Waterloo, Waterloo, Ontario, Canada
  1. Correspondence to Dr Joshua S Ng-Kamstra, Department of Critical Care Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; josh.ngkamstra{at}gmail.com

Abstract

Physicians played a key role in advancing Canada's recent assault weapons ban. Indeed, after announcing the ban in May 2020, the Trudeau government thanked Dr. Najma Ahmed and the group Canadian Doctors for Protection from Guns (CDPG) for their support of responsible gun control measures. In this piece, we explore the context in which CDPG was formed, the strategies used by the group in building nationwide support for gun control measures, and the public health framing of their messaging that proved critical in engendering political change. The work of CDPG holds valuable lessons for physicians seeking to engage in political advocacy by bearing witness to the harms experienced by their patients.

  • gun violence
  • firearms
  • public policy
  • public health
  • health policy
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On 1 May 2020, Prime Minister Justin Trudeau announced a ban on 1500 models of assault-style weapons, effective immediately. While the move was criticised by some, including opposition leader Andrew Scheer, as a political exploit in response to Canada’s deadliest mass shooting in Nova Scotia 2 weeks prior, the ban affirms years of advocacy against gun violence and in fact was supported by 78% of Canadians.1 That same day, Deputy Prime Minister Chrystia Freeland publicly thanked Dr Najma Ahmed and the group she founded, Canadian Doctors for Protection from Guns (CDPG), for their longstanding support of responsible gun control measures.2 The commendation suggests how their work can provide insights for all physicians seeking to change policies, especially in the face of vocal opposition, threats, bureaucratic hurdles and the political uncertainty of election cycles.

How do physicians contribute to determining policy at a national level in this way? By encouraging the opening of a policy window. The term, coined by political scientist John W Kingdon, describes how policy change occurs at the convergence of three streams: first, the problem stream requires clear identification of an issue of societal import; second, the policy stream requires the availability of a practicable policy alternative to address the problem; finally, the political stream requires sufficient will and power of actors to enact the change.3 When these align, a policy window opens.

Dr Ahmed’s resolve to address the problem of Canadian gun deaths began on a dark day in Canadian history, 22 July 2018. A gunman with a 0.40-calibre Smith & Wesson semiautomatic pistol killed two young girls and injured 13 others before ending his own life on Danforth Avenue, in Toronto’s Greektown. Across the Don Valley, Dr Najma Ahmed mobilised her team at St. Michael’s Hospital to treat the injured. As she worked, she decided that she could not remain silent while people in her city suffered preventable injury and died, especially in the face of a trauma becoming frighteningly familiar to Canadians. From 2000 to 2018, over 14 000 Canadians died from firearm injuries, and among 23 high-income countries, Canada has the fifth highest rate of firearm-related deaths.4 5 As deaths from gun violence increased, physician voices opposing the proliferation of firearms grew louder. In the fall of 2018, Annals of Internal Medicine published a position paper from the American College of Physicians, Reducing Firearm Injuries and Deaths in the United States.6 The response of the National Rifle Association (NRA), that ‘someone should tell self-important anti-gun doctors to stay in their lane’,7 inadvertently brought together an international alliance of physicians to support gun control. Galvanised by the NRA’s casuistry that conflated harm reduction with egotism, physicians organised around the hashtag #ThisIsMyLane, generating over 228 417 tweets and collecting 425.6 million views in 1 week.

Building on the momentum of this nascent physician movement, Dr Ahmed sought the counsel of advocates across Canada to bring together a network of physicians to collate scientific evidence for developing effective policy. Among them was Dr Philip Berger, who had brought a successful Charter challenge to the Federal Court of Canada in 2014, restoring health coverage to over 100 000 refugees. Dr Berger recommended Mr Christopher Holcroft, a consultant who had worked with Canadian Doctors for Refugee Care. Along with Drs Lynn Wilson, Julie Maggi, John Kortbeek, Paola Fata and Alan Drummond, they founded CDPG. Medical students and residents from across the country added valuable energy to the movement, allowing the movement to scale deep into the medical community. The group began its work by conducting rigorous research, undertaking a review of the academic literature, lay media, current legislation, the positions of the federal political parties and the arguments of gun rights organisations.8 An abundance of evidence pointed to an association between the proliferation of firearms and avoidable injury and death.9–13

Given the complexity of gun deaths in Canada including a substantial proportion attributable to suicide,5 no single policy solution would be sufficient to eliminate the public health burden of firearm violence. The group therefore committed to progressive policy change with a multi-step approach, addressing the individual dimensions of Canada’s gun violence problem. With the available evidence, CDPG supported an assault weapons and handgun ban in addition to measures to address the social determinants of firearm injury. In its position statement, CDPG called for:

  1. The introduction of legislation and other tools to reduce the prevalence of firearms, such as restrictions on gun ownership, an amnesty programme to recover firearms currently in circulation, and a strategic approach to reducing the illegal sale of guns and the importation of firearms from other jurisdictions.

  2. Funding and infrastructure for research on the epidemiology of firearm injury and death including the role of social determinants such as poverty, mental illness, racial discrimination and social isolation, as well as the effectiveness of strategies to reduce firearm-related injuries and deaths.

The next steps toward enacting policy change were to bring the organisation’s internal dialogue to a national level, to speak directly with policymakers and to change the public discourse. CDPG conducted policy entrepreneurship, leveraging policy networks, studying the motivations and interests of all relevant actors, and building relationships with other organisations, while maintaining a clear focus on the policy problem.14 Fourteen national or provincial medical organisations endorsed CDPG’s position statement, including the Canadian Association of General Surgeons, the Ontario Medical Association and the Trauma Association of Canada, as well as nursing groups and the National Council of Women of Canada. With clear policy goals and a network of support established, CDPG sought to engage with existing legislation under debate at the time in Ottawa. On 20 March 2018, Ralph Goodale, then Minister of Public Safety and Emergency Preparedness, introduced Bill C-71 to the House of Commons. Bill C-71 addressed gaps in existing firearm legislation by:

  • Abolishing the 5-year statute of limitations for background checks.

  • Requiring that persons transferring a non-restricted firearm verify that the recipient has a valid license.

  • Ensuring that gun retailers keep a minimum dataset on guns sales for 20 years.

  • Imposing limitations on the transport of prohibited and restricted firearms.

  • Guaranteeing that data from the Long-Gun Registry be preserved and accessible.

The passage of this bill through the Senate remained uncertain: no Canadian government had passed legislation to control firearms in more than 20 years. On 18 February 2019, CDPG leadership testified before the Standing Senate Committee on National Security and Defence. CDPG’s National Day of Action in support of C-71 on 3 April 2019 was attended by over 1000 individuals and covered in over 80 media stories. Physicians across the country enlisted their identities as healthcare providers to counsel on a policy issue. The moment was an important one, because, in general, the gun lobby’s rhetoric had so far been able to isolate discourse on gun violence to individual acts, whereas CDPG’s testimony expanded gun control to an issue of public health in Canada. On 28 May 2019, the Senate passed Bill C-71 after its third reading; it received Royal Assent and became law on 21 June 2019. Despite its importance, C-71 did not prohibit the proliferation of handguns and rapid-fire assault rifles.

Following the Christchurch Massacre in March 2019, in which 51 people were killed and 49 injured, New Zealand Prime Minister Jacinda Ardern’s government passed legislation to ban all semiautomatic firearms and remove them from circulation within 1 month of the massacre—a bold initiative that enjoined other governments to do the same. Ardern’s government could react quickly in large part owing to Ardern’s own extensive knowledge on gun control issues, having been a member of the opposition during two previous attempts to reform gun law in 2012 and 2017.15 The speed of her action echoed John Howard’s 1996 response to the Port Arthur massacre, when Australia’s Conservative prime minister passed firearm restrictions after only 12 days.16 The loss of life in Christchurch showed once again that gun control is a public health and safety issue, an argument that CDPG made to Canadian political parties in the runup to the 2019 federal election.

CDPG sought to show parties that a strong stand on firearms policy could benefit a political party at the ballot box by connecting the issue to broader constituencies and societal concerns. Polls had shown that Canadians were overwhelmingly in favour of stricter gun control measures, specifically supporting handgun and assault weapons bans.17 18 Shifting the gun control discourse toward public health at a time when public polling showed strong support for new measures convinced legislators this was a winning policy issue. In a response to a CDPG election questionnaire, four of the five major political parties committed to introduce measures to restrict access to guns. After running on a strong platform of gun control, including a ban on military-style assault weapons, the Liberal Party won the most seats in the election and formed government. This demonstrated clear signs of a strong mandate for action and the makings of a policy window. CDPG supported other civil society organisations with extensive expertise and history with gun control issues, including PolySeSouvient, Danforth Families for Safe Communities and the Coalition for Gun Control, to position action on gun control as a policy and political imperative. Following the 2020 Nova Scotia attacks, in which military-style assault weapons were used to kill 22 people, the leadership of these organisations collectively penned an open letter to Minister of Public Safety Bill Blair in support of an immediate assault weapons ban.19

Prime Minister Trudeau’s May 1 announcement marked the intersection of three key streams, where problems, policies and politics converged, the junction where Canadians now stand. The policy window was opened by the committed actions of a broad coalition including community groups, physician voices and elected officials who acknowledged strong public support for new legislation. In building relationships with both politicians and other interest groups, CDPG stayed firm in its commitment to protecting public health, while recognising key and pressing issues relevant to policy makers and Canadians. Canada’s next steps should be made following evidence-based medical recommendations—a lane well-worn by the steps of countless physicians. There is much work yet to do: tens of thousands of assault weapons remain among Canadians,20 handguns remain legal, and there is a great deal to learn about the social determinants of gun violence. CDPG remains committed to reducing the prevalence of firearms, growing the evidence base, engaging with policy makers, the public and other organisations, and using their own hard-gained experiences to create future policy windows.

When treating a gunshot wound, trauma surgeons follow the trajectory of a bullet through the body and attempt to reverse its effects, treating haemorrhage, suturing together what it divided and restoring normal anatomy where possible. To prevent gun violence, the trajectory can and must be traced back further: to the muzzle of the gun, the magazine which held the bullet, the finger that pulled the trigger, the hands that bought and sold the weapon and to the corporation that manufactured it. Bullets not only reverberate through patients’ bodies, but also through our society, causing incalculable trauma beyond tissue, blood vessels and organs. They destroy the psyche of families and the fabric of communities, which even with the best tools and training, no surgeon can fix. As witness to these harms, physicians are uniquely positioned to advocate for the prevention of firearm injury.

Acknowledgments

The authors thank Dr Najma Ahmed, Dr Philip Berger and Mr Christopher Holcroft for providing factual interviews informing the content of this piece.

References

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Footnotes

  • Twitter @joshngkamstra

  • Contributors JSN-K and JL drafted the manuscript, reviewed its content and approve the submitted version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JSN-K is an executive board member of Canadian Doctors for Protection from Guns (CDPG). The opinions expressed in this article do not necessarily reflect those of CDPG or the authors’ institutions.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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