Has the public health framework failed in the fight against gun violence?

By Cara Anthony, Firearm Violence Reporting Fellowship

When Jonathan Metzl published a book about America’s complex relationship with guns, it quickly gained traction and praise. 

The Nashville-based psychiatrist and author made TV appearances and his book was named a top pick by editors and critics at The New York Times. 

But when people actually took time to read Metzl’s book, they realized it wasn’t just another story about mass shootings. It took a critical look at the public health approach to gun violence, answering the question: Where did public health go wrong? 

Metzl said he sees gun violence as an urgent public health crisis. 

“But I also argue that public health missed the boat about guns,” Metzl said. “I’m asking us to think more critically about the public health framework.”

In his book, “What We’ve Become: Living and Dying in a Country of Arms,” Metzl explains why the public health approach to gun violence has to change to be effective in combating the problem. Red flag laws, data collection and policy changes will not stop the bleeding, he said during his book talk at Health Journalism 2025 in Los Angeles.

He sees guns as a  “democracy issue” as well as a public health issue. The public health framework focuses on counting injuries and fatalities, but that’s not enough. He wants his peers to understand the role of politics, identity, racism and power.  That’s missing at the moment, he said.

“Public health, too, will be challenged to reinvent itself,” Metzl writes in the book. “It has been too easily cast as a tyrannical foil to white liberty. Biomedical frameworks are important for tracking injuries and deaths, but at times blind us to the larger agendas of gun politics.”

To make his point, Metzl rewinds the clock to 2018 when a white gunman killed four young adults of color at a Nashville Waffle House. Metzl explores the role of politics, racism and power as he dissects the shooting in his book. 

During his book talk, Metzl said his objective is not to disavow the work of his peers. Public health research has played a vital role in unearthing important statistics. Gun violence is still the leading cause of death for children in the U.S., according to the CDC. Nearly 47,000 people died of gun-related injuries in the United States in 2023.

With those figures in mind, Metzl wants to deepen the conversation. He critiques public health strategies employed to combat firearm violence, and he explains why old public health strategies won’t work. The framework used in anti-tobacco, seatbelt and HIV campaigns were successful, but guns are different, Metzl said. 

“The daily violence we live with and have normalized is not normal,” Metzel wrote in his book. “Even now, the decisions America makes about guns share who we are and who we will become.”

Cara Anthony is a Midwest correspondent for KFF Health News. She is also a 2025 Firearm Violence Reporting Fellow.