A group of the country’s former top doctors have taken the unprecedented step of asking President Joe Biden to green-light a Surgeon General’s Report on gun violence. They say the move is long overdue, and that it would generate a renewed push to treat gun violence as a public health issue.

In a letter mailed and emailed to the White House on December 14, exactly 10 years after the Sandy Hook school shooting, four former surgeons general implored Biden to direct their successor, Surgeon General Vivek Murthy, to prepare a report that would explore the causes of and potential solutions to gun violence in America, an epidemic with an annual death toll that eclipsed 48,000 for the first time in 2021.

“There is little question that firearm violence is a public health crisis,” the letter to Biden reads. “And yet, unlike for homelessness, opioids or other determinants of health, there has never been a U.S. Surgeon General’s Report on gun violence in America. Not one.”

Surgeon General Vivek Murthy testifies during a Senate Finance Committee hearing on youth mental health in February. AP/Graeme Sloan

Surgeon General’s Reports have a long history of defining the national conversation around public health crises and influencing the ways in which federal agencies and state and local public health officials address those crises. The landmark publications are rare and typically reserved for pressing public health challenges that demand immediate national attention, such as one about cigarettes that established tobacco products as a serious health risk. Other reports have covered alcohol, drugs, mental health, and suicide.

Though several prominent physicians and members of Congress have called for surgeons general to commission a report on gun violence, the letter is perhaps the most high-profile request and the one with the most credibility.

The signatories included Dr. Antonia Novello; Dr. Joycelyn Elders; Dr. David Satcher; and Dr. Richard Carmona; who served as surgeons general under Democratic President Bill Clinton and Republican Presidents George H.W. Bush and George W. Bush. The former surgeons general, who formed a Surgeons General Consortium, originally drafted the letter in early 2021, but did not formally send it to the White House until now.

A White House spokesperson did not immediately respond to a request for comment.

The first modern Surgeon General’s Report, released in 1964 by then-Surgeon General Luther Terry, concluded that cigarette smoking, at the time a far more popular practice, was a cause of lung cancer. That report and more than a dozen follow ups led to national efforts that helped cut smoking rates by nearly two-thirds. 

The success of the reports on tobacco inspired Surgeon General’s Reports on other health risks. In 1986, Surgeon General C. Everett Koop published a groundbreaking report on  HIV and AIDS that broke with the anti-gay viewpoints of conservatives in President Ronald Reagan’s administration. A condensed version of the report was mailed to every household in the United States, dispelling myths about how HIV spreads and highlighting condom use as an effective preventative measure. 

Since then, several reports have studied suicide and mental health, and at least one examined youth violence, though none exclusively examined firearms or gun violence. The report on youth violence, however, did conclude that firearms increase the severity of youth violence.

Surgeon General’s Reports are not authored by the surgeon general or their staff alone. Instead, the surgeon general convenes dozens of subject matter experts, medical professionals, and advocates. Such a diverse group could be especially helpful for a divisive issue like responding to gun violence, Carmona said. Like previous reports, it could help dispel myths about gun violence and parse existing research about which policies work and which don’t.

In their letter, the doctors also reject the notion that a Surgeon General’s Report would advocate for “gun control” policies.

“Incrementally, this can invoke change over time in what is now a very hyper-partisan, caustic issue,” Carmona told The Trace. “It can bring people together around how we keep our society healthy and safe and prevent hundreds and hundreds of needless shootings every year.”

Without approval from the White House and the Department of Health and Human Services, which provides the surgeon general’s funding, the surgeon general alone lacks the resources and authority needed to commission a report. The Office of the Surgeon General did not respond to a request for comment. Congress could sidestep the president and require a report, but a bill to do just that, sponsored by U.S. Representative Robin Kelly, a New York Democrat, is stalled in the House

Though most major medical organizations now consider gun violence a public health issue, efforts to provide federal funding for research and evidence-based prevention strategies have long been politically divisive. For years, Congress effectively barred the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) from funding gun violence research. It wasn’t until 2019 that Congress ended the two-decade freeze with $25 million in annual funding.

Murthy has not shied away from advocacy around gun violence — both before and after he became the nation’s top physician. As the founder of Doctors for America, he argued for an assault weapons ban and called on Congress to restore funding for gun violence research at the CDC and NIH. The National Rifle Association opposed Murthy’s confirmation when he was first nominated in 2013 by President Barack Obama.

During his campaign and since taking office, Biden himself has acknowledged gun violence as a public health crisis. He’s taken steps to provide millions in funding for community-based programs that treat it as such, encouraged states to use Medicaid to cover hospital-based violence intervention, and proposed doubling the annual funding for related research. But Biden’s administration has also resisted calls from advocates to appoint a gun violence prevention czar and establish an office within the White House to focus on gun violence. 

In their letter, the former surgeons general note that more than 40,000 people die from firearm-related injuries annually, making firearm violence one of the top five causes of death by injury. In 2021, the number of firearm deaths rose to 48,832, according to CDC data — an all-time high. Suicides also rose at a record pace.

Dr. John Maa, a surgeon in San Francisco who has pushed for a Surgeon General’s Report on gun violence, said such an undertaking could help prevent the medical trauma caused by gun violence.

“It would be the most credible reference and resource so that all local municipalities and states can use it to inform their policies,” Maa said. “I think a Surgeon General’s Report could help policymakers in our state capitals create better laws.”

Dr. Peter Masiakos, a trauma surgeon and co-director of the Massachusetts General Hospital Center for Gun Violence Prevention, helped organize the letter. He, along with Carmona and more than a dozen other doctors, researchers, and public health and safety professionals, published a compendium of articles and perspectives on gun violence in the journal Current Trauma Reports in 2020. The collection, Masiakos said, was intended to serve as an early blueprint for a Surgeon General’s Report.

“Everybody is speaking about how this is a public health issue, but the person who’s most capable of galvanizing a public health response has not been charged with that,” Masiakos told The Trace. “It’s probably the most important public health crisis in America now. And if the surgeon general, the public health director, can’t say that, then it becomes diluted.”

Correction: An earlier version of this story misspelled Dr. Peter Masiakos’ last name.