Surgeons working in ASCs rarely confront the daily reminders of violence that urban ED physicians take as a mainstay of their professional lives. ASCs mostly are located in suburban, more affluent areas. The procedures and surgeries often are elective, so the population of patients served by ASCs is self-selectively better off than the people who wait in EDs for medical treatment. Some surgeons are calling on ASC physicians to raise their voices to help stop the structural violence that is tearing apart some urban areas and robbing thousands of young people of their childhoods.

There is a movement of trauma surgeons who have said they cannot sit silently anymore, and all surgeons can join them, notes Carrie A. Sims, MD, PhD, FACS, associate professor of surgery at The Hospital of the University of Pennsylvania and the Presbyterian Medical Center of Philadelphia.

“We need to talk about what leads to increased violence in an urban center, what we can do about it as a society, and [what we can do about it] as individual practitioners,” Sims says. Structural violence is a public health crisis, which affects the larger community and society. Violence is the number one killer of healthy black men; yet, health professionals often stay silent about it, Sims says.

“Surgeons who do colonoscopies obviously care about public health as well. We advocate healthy diets; we try to prevent cancers,” Sims says. “And just like that, we as surgeons need to advocate for preventing things we know contribute to the public health crisis of violence.”

The term “structural violence” acknowledges the role society plays in violence. This role includes proliferation of firearms and generational housing redlining, in which people who lived in certain urban neighborhoods were denied loans that would help them buy houses and improve their properties, Sims explains.

“Inequality is the biggest predictor of violence in cities,” she says. “How do we address these inequalities that are influenced by race so we can improve the outcomes I care about as a trauma surgeon?”

Societal solutions include early childhood education, ending childhood hunger, improving housing opportunities, and addressing other socioeconomic factors. Surgeons also can speak up about guns.

“What do we do about regulating those? That’s a big, hot topic,” Sims says. “Gun violence gets a lot of publicity when it involves white people in mass shootings.”

But the subject is less visible to many people when it is the everyday mass violence involving African-American kids shot in the cities, she says.

“There’s a myth that it’s all gang related, but that’s not true. It is normal people violence happens to, but they live in a poor environment,” Sims says.

When state legislatures debate actions to reduce violence, surgeons should speak up. Trauma surgeons can describe the physical impact of gun violence.

“We can raise awareness that the policies we put in place really have an impact on our patient population,” she says. “Surgeons have a social responsibility to advocate for improving the circumstances of all members of our society. It’s not enough to patch up the patient; we have to advocate for improving the structure of our society so every person has an equal opportunity for health, liberty, and the pursuit of happiness.”

Sims suggests surgeons take these actions to draw attention to the problems of structural violence:

  • Step up to the plate.

“If there is a mass shooting, then every surgeon should step up to the plate and come in to operate,” Sims says. “If the local system is overwhelmed by trauma, then come in and lend a hand.”

  • Examine inward biases.

“Personally, I think people need to look at their own biases and do a self-assessment in terms of how they look at patients and members of society,” Sims says. “Do critical analyses of your own biases.”

  • Advocate for change.

“If you want to see change, then you have to advocate for the things we know address violence from a public health perspective,” Sims says. “You have to vote with your ballot, vote with your voice, and let people know you care about things contributing to structural violence, like poverty and race, and discuss this issue.”

  • Hold grand rounds.

“We can have grand rounds about structural violence,” Sims offers. “Also, you can raise the issue of violence as a public health problem in your hospitals. This is an easy way for people who aren’t trauma surgeons to see this issue.”

  • Support statements on violence.

Various surgeon and trauma organizations issue statements about gun violence, and concerned surgeons can lend their support to these efforts. It is a polarizing topic from a political perspective, but can be a unifying topic from a public health perspective. “The ways we’ll make progress is to look at violence as a public health problem and also to look at the implications of structural racism,” Sims says.

For instance, Sims pointed to research from 2017 that found that gunshot violence can spread as if it were an infectious disease. (Editor’s Note: Read much more about this investigation and methodology online at: https://bit.ly/2S8N37p.)