Tuesday, May 06, 2014

Gun Violence is a Public Health Emergency

It took only eleven minutes to transform a quiet elementary school into the scene of one of the deadliest school shootings in U.S. history. On December 14, 2012, Adam Lanza entered Sandy Hook Elementary with a Bushmaster Model XM15-E2S semiautomatic rifle. He used the weapon to murder twenty school children and six adults. One state trooper warned the medical personnel who arrived at the school to formally declare the victims dead: “This will be the worst day of your life.”
The Sandy Hook shootings prompted an outpouring of national grief and outrage. Yet sadly, this tragedy—while especially shocking and visible—only represents the tip of the iceberg when it comes to deaths from gun violence. Every day in the United States, friends and family must make funeral preparations for an average of 86 peoplewho were intentionally or unintentionally killed with a firearm.
If measles or mumps killed 31,672 people a year, we would undoubtedly consider the situation to be a public health emergency. And indeed, gun violence shares many characteristics with other widespread safety threats that have been framed as public health issues.
In a Q&A published in a 2008 bookThe Contested Boundaries of American Public Health, epidemiologist Mark Rosenberg recalls early efforts to frame gun violence as a public health issue in the 1980s. Finding that the burden of deaths from guns in the United States was similar to those of cars, he realized that gun violence was an area where public health could “make a big contribution and save lives by applying the same kind of science that had been applied to road traffic crashes.”
Indeed, like motor vehicle deaths, gun fatalities result from a consumer product that is integral to many Americans’ lives. Yet both cars and guns can be made safer with technology and engineering—air bags in cars and loading indicators for guns.
But efforts to frame gun violence as a public health challenge have met with considerable resistance, most notably from gun lobby groups, such as the NRA.
The NRA is a powerful force in American political life that attracts many supporters, not only with its ideological positions, but with its message of self-empowerment. And the organization has long and vociferously opposed the framing of gun violence as a public health issue, portraying research on the subject as biased and misguided. For instance, the NRA’s chief lobbyist, Chris Cox, told the New York Times that the CDC was guilty of publishing “political opinion masquerading as medical science.”
The NRA has worked to translate their objections into policies that circumscribe public health research on the effects of gun violence. In the mid-1990s, after a failed campaign to eliminate the CDC’s National Center For Injury Prevention, gun lobbyists helped persuade Congress to include language in its budget stating that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”  (If the NRA is right about everything they preach, why are they so afraid of the data?)
Despite this limitation, the agency has since developed other mechanisms to study causes of violent deaths, notably the National Violence Reporting System. But to this day, the CDC’s funding level for research explicitly devoted to gun violence prevention remains at $0. And according to Dr. David Hemenway, director of the Harvard Injury Control Research Center, due to fears of getting attacked by the NRA lobby, many foundations have avoided funding such research. (Do you think Bill and Melinda are afraid of the NRA?) “It’s one of the reasons that there’s been relatively little gun research compared to other research in public health,” Dr. Hemenway says.
More recently, the NRA succeeded in adding a provision into the Affordable Care Act to limit doctors’ ability to gather data about their patients’ gun use. The Washington Post dubbed this provision “a largely overlooked but significant challenge to a movement in American medicine to treat firearms as a matter of public health.”
Then, in 2011, Florida Governor Rick Scott signed into law a “docs vs glocks” bill, which banned physicians from asking their patients about gun ownership. In 2012, a federal judge permanently blocked this NRA-backed law because it violated the First Amendment rights of doctors. Nonetheless, such laws and provisions indicates the extent to which policymakers have attempted to limit medical and public health conversations and research on gun safety.
Despite this already remarkable influence in setting and limiting the terms of public health research, this year the NRA has wielded its power in an extraordinary new way by obstructing President Obama’s nomination of Dr. Vivek Murthy as U.S. Surgeon General. The organization opposed Dr. Murthy’s characterization of gun control as a health issue and his support of regulatory measures, such as mandatory safety training for gun owners.
But by blocking Dr. Murthy’s nomination, the NRA prompted prominent medical and public health voices to take a stand. In a remarkable op-ed, the New England Journal of Medicine stated that “the NRA is taking its single-issue political blackmail to a new level.” And in April 2014, Michael Bloomberg took a bold step into the ongoing debate, announcing that he would donate $50 million of his own money to counter the NRA.
The New York Times describes how Bloomberg intends to restructure current gun control advocacy efforts to more effectively counter the NRA. Part of the idea is to combine forces and model advocacy efforts on the success of other safety-related groups, notably Mothers Against Drunk Driving. The resulting new group, Everytown For Gun Safety, has already produced an ad that directly challenges claims made by the NRA.
Whether these new strategies and influx of money can promote effectively a public health perspective on gun violence and safety interventions remains an open question with high stakes. In fact, even after the Sandy Hook shootings of 2012, many states have been loosening their gun restrictions. Georgia, one of the most prominent and recent examples of this trend, recently passed into law a bill that allows licensed gun owners to carry their weapons in schools, churches, bars, and airports. The public is often unaware of the extent to which gun owners may legally carry and display their weapons in public spaces across the country.
What policy changes do gun safety advocates seek? A recent Massachusetts report identified 44 strategies to reduce gun violence that all committee members, including public health professionals and gun owners, endorsed. Of the range of possible strategies to reduce gun violence, strengthening the existing background check system has the most public support. In fact, although the NRA as an organization does not support universal background checks, a 2013 poll found support among 74 percent of NRA members. (The NRA doesn't even support their own members!)
This approach is also supported by public health research. As reported by Nora Caplan-Bricker in The New Republic, a 2014 study found that the murder rate in Missouri jumped 16 percent after the repeal of a state law that required anyone purchasing a handgun to obtain a permit indicating a background check had been passed.
Safe storage practices and more safely designed guns would also likely make an impact on reducing the number of unintentional gun deaths among young children. As Dr. Hemenway told WBUR’s All Things Considered“We have childproof aspirin bottles; we should have childproof guns.”
Yet entrepreneurs seeking to market and sell “smart guns,” or weapons which can only be fired by authorized users, have encountered harassment and outrage from gun enthusiasts. This month, a Maryland gun dealer who had intended to sell the nation’s first smart gun backed down after enduring protests and death threats. And fewer than 20 states have enacted laws to hold adults criminally liable if they fail to safely store their gun, enabling children to access the weapon.
Former U.S. Surgeon General Julius Richmond and medical economist Rashi Fein have proposed three essential factors involved in addressing a societal problem: scientific data, a social strategy guiding the pursuit of public health goals, and political will. Public health researchers have sought to collect data on the effects of gun violence despite the obstacles, and gun safety advocates are currently seeking new strategies.
But ultimately, it seems that whether gun violence can be framed as public health problem will come down to political will. A public health frame for this fully loaded American issue can only be effective if it is built on a narrative of shared American values. These must include not only the second amendment, but also protecting our rights to life, liberty and the pursuit of happiness.

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