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 book, The 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.

CDC Classifies Overdoses From Opiates and Heroin As An Epidemic

It is amazing to me that in the President's State of the Union address, in Jon Stewart's interview with Nancy Pelosi, or in any of the other political coverage recently, not one mention has been made of what I consider to be two of the greatest challenges facing our country today: the number of children and adults who are killed by guns every day, and the heroin epidemic sweeping the country.  I can't understand how our elected officials can keep arguing about everything else and ignore this.

To the Editor:

Philip Seymour Hoffman’s tragic death puts a very public face on an epidemic health condition that is ravaging families across New York and the United States (“Actor’s Heroin Points to Surge in Grim Trade,” front page, Feb. 4).

The Centers for Disease Control and Prevention has classified overdoses associated with prescription opiates and heroin as an epidemic. The loss of life and the impact on communities across the country have been front-page news. There is little debate that there is a significant cause for alarm.

Unfortunately, state legislatures and policy makers have failed to address this public health crisis with prevention, treatment and recovery supports adequate to reverse its impact.

We will make progress only when there is increased prevention and education targeting at-risk populations, widespread availability of Naloxone to reverse the symptoms of an overdose, treatment on demand and services to help people in recovery to stay in recovery. Gov. Peter Shumlin of Vermont is to be praised for his leadership on this issue. We need others to join him.

JOHN J. COPPOLA
Executive Director
Alcoholism and Substance Abuse
Providers of New York State
Albany, Feb. 4, 2014

Childhood Obesity Rates Drop

To Fight Obesity, a Carrot, and a Stick

By TINA ROSENBERG

New York Times

November 16, 2013, 2:35 pm

Childhood obesity, at long last, may have peaked — even among the poor, where the problem is most prevalent. Between 2008 and 2011, according to a study from the Centers for Disease Control and Prevention, 19 states and territories saw a small but significant drop in obesity rates among low-income preschoolers.

This is a problem that many people assumed would only get worse. So how has this small bit of success been achieved?

One factor is certainly an extensive behavior-change campaign; official America is now bribing, cheering and badgering us to eat fruits and vegetables, exercise, drink water instead of soda and cut down on screen time. Another is that cities and civic groups are doing creative things to bring healthier food to poor neighborhoods. These changes help. But there may be a more direct reason for the progress against child obesity.

The C.D.C. study focused on preschool-age children, from 2 to 4 years old, most of them enrolled in the federal Special Supplemental Nutrition Program for Women, Infants and Children, known as WIC. WIC provides vouchers to pregnant and nursing women, and mothers of children under 5 to buy specific foods.

In 2009, WIC changed its rules. There are new vouchers specifically for produce, for example. Milk must be reduced-fat, and bread and rice must be whole-grain. And stores participating in WIC must carry these items. You can see that change in corner stores and bodegas across the country, including, for example, Luciano Espinal’s Deli Grocery, on Lehigh Avenue in North Philadelphia.

Mr. Espinal’s store has two aisles and a deli counter in the back. There are similar stores all over the neighborhood, their shelves filled with snack cakes, chips, soda, white bread. The only fresh foods are the iceberg lettuce and tomatoes needed by the deli counter, and maybe potatoes and onions.

But Mr. Espinal’s store accepts WIC vouchers. So he carries things non-WIC stores do not: apples, oranges, green peppers and bananas. He also carries the WIC-required whole-grain bread, brown rice and 2 percent milk.

Of course, people could buy more of the unhealthy stuff with their own money. But the evidence says they don’t. Yale’s Rudd Center for Food Policy and Obesity looked at purchases by WIC participants in Massachusetts and Connecticut, including what they bought with their own cash. After the WIC changes, participants bought significantly more whole-grain bread and brown rice and reduced-fat milk, and far less white bread, whole milk, cheese and juice.

Attitudes are changing. Access to healthy food is increasing. But that doesn’t address what is probably the most important problem: cost. On a limited budget, people buy cheap and unhealthy food. Community groups and cities can’t solve that problem — not for more than a handful of people at a time, anyway.

But the federal government can. The success of the WIC reforms proves it. The program matters: half of all infants and a quarter of all children under 5 in the United States will be on it at some point. But with nine million participants, it is dwarfed by the Supplemental Nutrition Assistance Program, or SNAP — commonly known as food stamps — which reaches more than 47 million people. Food stamps keep people from starving. But you cannot buy fresh produce on $1.40 per meal. (Let’s contemplate the extra medical bills we’ll be paying because of Congress’s decision to let the Recovery Act’s increases in food-stamps benefits expire.) SNAP needs some help.One strategy is to provide financial incentives to buy fruits and vegetables. This is happening in many farmers’ markets; Philly Food Bucks, for example, gives people a $2 coupon for every $5 in food stamps they spend on produce at participating markets. Food stamps sales at these markets have increased by nearly 400 percent. In some states, eligible produce must be locally grown, a change farmers appreciate.

The idea is spreading to supermarkets. This summer the Agriculture Department released results of its Healthy Incentives Pilot in Hampden County, Mass. Supermarket shoppers earned 30 cents for each food stamp dollar they spent on fruit and vegetables. Those in the program bought 25 percent more produce than the control group, at a cost of 15 cents per day.

These programs are lovely, but they reach relatively few people, and they are expensive. Another strategy is harsher: Copy WIC and limit the foods that food stamps can buy. Such a change could cover the whole country in one administrative stroke. And, of course, it is virtually free. With even more cuts in food stamps looming in the farm bill,that’s important. Minnesota, Mississippi and New York asked the Department of Agriculture for permission to take soda or candy out of SNAP. Mississippi later withdrew its request. The department said no to New York, saying the program was poorly designed. It told Minnesota that the state could not change the federal program’s definition of what could be covered.

None of the obstacles to limiting food stamps to healthier foods seem insurmountable. It is administratively simple to draw a line. But not politically simple. It’s not just that people on food stamps are an enormous market for soda and junk food. Big Soda has unusual allies. Restricting purchases is not controversial with WIC, which exists to supplement nutrition. But it is with food stamps, which exist to supplement income.

“There are people in the anti-hunger community who support a soda tax in general because it affects everyone, but they oppose banning soda from SNAP because it affects only poor people,” said Marlene B. Schwartz, director of the Yale Rudd Center.  “Their philosophical argument is, if it’s the right thing to do for everyone, then make it for everyone.”

Other approaches exist. A portion of food stamps benefits could be set aside for produce. Or states could use the guidelines they already follow — to little controversy — with sales taxes. More than half the states tax soda or junk food at a higher rate than the food tax rate — in effect, they do not consider them food.“Instead of arguing about healthy versus unhealthy, I would almost rather say what counts as food,” said Ms. Schwartz. “States already figured out what is and isn’t food.”

How Many Died Today?

Twenty years ago, the Congress of the United States sentenced thousands of its citizens to death. They attacked research on firearm deaths and injuries.  They attacked the Centers for Disease Control and Prevention for funding firearm research.  And to drive the nail home, the CDC saw $2.6 million stripped from its budget. Coincidentally, that is the same amount they had spent on firearms research the previous year.  Because there has been so little scientific research on firearms done, it has been impossible to enact measures to reduce the incidence of death and injury.  How many lives might have been saved had this action not been taken?  We will never know.

Joe Nocera, writing in an Op Ed piece for The New York Times, states that Slate's gun-death tally, which is included at the end of each of his blog posts, has recorded 7,897 deaths since the Newtown massacre last December-almost three times the total killed on Sept. 11, and nearly double the number of U.S. soldiers killed over the course of the nine-year-long Iraq War.

As astonishing as that number is, there is a glaring disparity between the C.D.C figures (they are still allowed to report death records) and Slate's running total.  The reason, Slate has explained, is that its tally is culled from news reports, and the C.D.C figures are taken from death records. "Using the most recent CDC estimates. . .it is likely that as of today, 9/5/2013, roughly 23,381 people have died from guns in the United States since the Newtown shootings.  Compare that number of deaths reported in the news and you can see how under-told the story of gun violence in America really is. "

Here is the gun report for September 6, 2013:

A 2 month old in Minneapolis, a 6 month old shot by her 3 year old brother in Charlston, S.C., a 12 year old boy shot by his 15 year old cousin in New Mexico, a 14 year old boy in Newark, N.J., a 16 year old and another man in one shooting in Philadelphia, 4 people in Charlotte, N.C., a 72 year old woman in Longmont, Colorado, a 26 year old woman in Tennessee, a passenger on a bus shot by another passenger in Houston, Texas, a 29 year old man in Austin, Texas, a man in his 20s in Chicago, a 33 year old and a 44 year old in a murder-suicide in Minnesota, a 38 year old man in Yakima, Washington, a man in Boston, Massachusetts, a 36 year old man in Rochester, NY, a man in Tallahassee, Fl, a 19 year old in Toledo, Ohio, a man in North Kansas City, MO, a man in Houston, Texas, a 55 year old man and a 20 year old man in Elkhart, Indiana, a 21 year old in Portage, Wisconsin.

These were real people, folks.