Thursday, July 19, 2018

We Need to Look at Gun Deaths as a Public Health Issue

By Melissa and Patrick Finnegan

In the wake of a number of recent school shootings – including the Marjory Stoneman Douglas High School shooting in February in Parkdale, Florida – we saw the re-emergence of gun policy in national headlines and social media.  In some ways, developments took a familiar turn; exasperated members of the public call for better gun regulation while gun-rights advocates – led by the National Rifle Association – argue that such measures are futile and infringe on individual rights. In the estimation of the latter, the only way to protect against school shootings is more armed personnel in schools.  The difference this time is that student survivors from Marjory Stoneman Douglas High School launched a campaign to reform gun policy that has the potential to become a sustained national movement.

We believe that this is the time to have a discussion about gun deaths and public policy, specifically from the public health perspective.  There is a qualitative factor in gun deaths that make them a public health issue.  The purpose of guns is to kill.  Whether it be in the context of animal hunting or use against another human being, the main purpose of a gun is to kill efficiently.  How a gun is used is, of course, integral to the discussion.  The fact remains, however, that even when utilized carefully and responsibly, a gun is a dangerous instrument, the use of which carries an elevated risk of injury and death, both to the self and to others.

To understand the effects of guns on U.S. society, we need to confront some basic truths.  Guns are ubiquitous in the U.S.  As civilian populations go, U.S. residents are heavily armed; with 42% of the world’s civilian-owned guns (see chart 2), our rate of ownership far exceeds all other countries in the world, including the runner up, Yemen, which is in the midst of a brutal civil war.  Gun related deaths average approximately 33,000 a year in the United States.  In our home state of Minnesota, 432 people died by guns in 2016, more deaths than were caused by opioid use (395) or traffic crashes (392).  Facts like these make gun deaths a public health concern.  While the majority of these deaths are suicides, the U.S. gun homicide rate still far exceeds any other high-income country (see charts 1 and 6). 

Although it may be tempting to assume that more crime explains our higher homicide rate, it turns out that U.S. violent crime rates are comparable to that of peer countries; the key difference is that assault in the U.S. is more fatal because it more often involves guns.  This holds for suicide attempts too (see charts 10-12); guns are far more effective tools of suicide than suffocation, poisoning, cutting, or other methods.  While “guns don’t kill people, people do” may be a popular slogan, it would be more apt to say that “guns don’t kill people, but they make it much easier.” 

With all of this in mind, we advocate approaching guns from the standpoint of public health.  As a society, we regulate access to hazardous things for health reasons all the time.  If it becomes clear that current regulations are inadequate in curbing preventable deaths, we attempt to change policy. Take the issue of opioids: the over-prescription of these drugs has led to widespread addiction-related deaths.  Although there are laws on the books that restrict access to opioids, these laws have failed to prevent a public health crisis.  As such, we as a country are now in the midst of a national discussion of which policies will be most effective in reducing opioid deaths.  Many of the proposals on the table involve restricting how often opioids are prescribed.  Opioids have their purpose in medicine, even when used with circumspection, but they still pose an elevated risk to patients. 

In addition, we restrict an individual’s use of a substance or product if there is a high risk of harm to the self or others.  Take alcohol and driving for example.  Alcohol use is regulated in our home state of Minnesota (as it is elsewhere): you have to be a certain age to purchase alcohol and providers (aka, bartenders) can choose not to serve you if you appear to be inebriated.  As a community, we have decided that – in this instance – limiting an individual’s alcohol consumption is both appropriate and desirable in the name of public safety.

It would paint an incomplete picture, however, to only talk about restricting access to opioids and alcohol without examining the underlying issues that lead to their abuse.  Family histories of addiction or mental illness, as well as poverty and other social determinants of health, are critical factors to understanding widespread alcohol or opioid abuse.  And so it should be when considering gun policy.  Our main point is that we must have a variety of policy tools at our disposal to address complex public health problems. 

Reducing gun deaths will require long- and short-term policy solutions, but also cultural change in how the U.S. public, broadly speaking, views guns.  We will briefly list some policy proposals we believe should be adopted or considered to reduce gun deaths.  This list is not exhaustive, nor is it meant to be definitive.  (This is a blog entry, after all.).

Firstly, we need good quality research on gun violence to craft good policy in the long term.  The Centers for Disease Control was only recently relieved of a ban on studying the causes of gun deaths.  In our home state, Minnesota Statutes, section 144.05, subdivision 5, prevents the Minnesota Department of Health from even collecting statistics on gun ownership.  Information on gun ownership can help inform public policy regarding – for example – the safe and secure storage of firearms, including the separation of ammunition.  Additionally, public policy would benefit from deeper research into the root causes of gun violence, including social determinants, public attitudes about violence, and mental health concerns.  As such, we advocate (a) the immediate reversal of Minnesota’s research prohibition, and (b) investment in health-based research on the causes of gun violence.

When discussing potential policy options, we should also distinguish between homicides and suicides.  In terms of homicide, it is also useful to separate mass shootings from “ordinary” murders. In the case of most ordinary murders, the perpetrator and the victim(s) know each other; material advantage or interpersonal dispute are the primary motives.  Mass shootings, while often involving revenge-based motivations, are less discriminate.  As such, the tools of each type of homicide are a bit different.

The AR-15 has become the preferred tool of mass shooters in the U.S.  As detailed in Tim Dickinson’s exposé on the AR-15, it was originally a military weapon designed to kill with maximum effectiveness.  Its high-velocity rounds and rapid rate of fire enable it to kill many people in a very small amount of time, even in its civilian iterations.  It is substantially more lethal than a 9mm handgun.  Additionally, its mass marketing in the past decade, coupled with the 2004 expiration of the assault weapons ban, has made it widely available.  Bump stocks – which increase the weapon’s rate of fire – and other customizable options have enabled it to become an even deadlier weapon.  As such, we advocate the re-institution of the ban on civilian ownership of the AR-15 and other assault weapons, as well as the accompanying accessories that increase the lethality of such weapons.  President Trump’s executive order to ban bump stocks seems like a step in the right direction, but it is still unclear if that policy will stick.

To be clear, we do not advocate a total ban on the possession of all firearms.  We do, however, believe that there should be universal background checks, as well as stricter permitting, licensing, and storage regulations.  The gun show loophole is a well-known issue that enables the purchase of guns without a background check at such events, which makes it easier for persons with criminal records to legally acquire firearms.  According to recent survey data, most people – including most NRA members – support universal background checks on all gun sales.  A number of studies strongly suggest that robust background and gun storage rules checks curb intimate partner killings and accidental child deaths.  In Switzerland, the country with the world’s third highest rate of gun ownership, persons who wish to purchase personal firearms undergo long background checks.  Owners must be licensed to possess semiautomatic weapons, rifles, and pistols, as well as keep them unloaded at all times except during immediate use.  While Switzerland’s rate of gun deaths is the highest in Europe, it is still one third of the U.S. rate. 

Connected to background checks and permitting, we also advocate the further exploration and adoption of Extreme Risk Protection Order policies.  These orders, effectively a restraining order for guns, enable the authorities to confiscate the firearms of persons deemed to be a violence or suicide risk.  Such laws should be carefully crafted to respect due process, of course, but also executable in a timely fashion to prevent imminent violence. 

One issue that gets brought up time and again after a mass shooting is mental health.  One common argument is that a more robust and accessible mental health system will curb gun violence.  When discussing the role of mental health in gun deaths, it is critical to distinguish between homicides and suicides.  Untreated depression is one of the main causes of suicide, so enhanced mental healthcare could very well have a positive effect.  If the ultimate goal of the public health view is to reduce all gun deaths, then policies that improve access to and the quality of mental healthcare must be a priority.

In terms of mass shootings, however, there is little convincing evidence that mental health interventions would have a positive effect.  As Olga Khazan wrote in The Atlantic in the wake of the Las Vegas shooting last year, “While improving access to mental health care might help lots of suffering Americans, researchers who study mass shootings doubt it would do much to curb tragedies like these. According to their work, the sorts of individuals who commit mass murder often are either not mentally ill or do not recognize themselves as such. Because they blame the outside world for their problems, mass murderers would likely resist therapies that ask them to look inside themselves or to change their behavior…very little violence is actually caused by mentally ill people.”  With this in mind, we advocate for investment in the mental healthcare system, with an emphasis on accessibility, especially for lower-income persons, while acknowledging that this policy intervention would most likely be effective in lowering suicides rather than homicides.  Additionally, it’s important to ensure that efforts to address mental health in connection with firearms do not maintain or exacerbate stigmas associated with mental health disorders.

While conventional mental health services may not prevent mass shootings, fostering a culture of inclusion and psychological support could prevent many school shootings.  As an NPR story on public approaches to school climate notes, “the very kids who bring weapons to school are more likely to report being bullied or threatened themselves. They may be fearful of gang violence and feel a need to protect themselves on the way back and forth to school.  Or, they may be individually ostracized and aggrieved.”  With this in mind, we advocate evidence-based school policies that stop bullying and discrimination, as well as establish student trust in school as an abuse-free environment.  We do not support arming teachers or other school personnel. And we cannot lay this burden on students alone, as the “walk up” movement has espoused.  Victims of school shootings should not be further victimized by accusations that if they had only been nicer to their fellow students, this tragedy wouldn’t have happened.  Anti-bullying and anti-discrimination efforts are important, but cannot solve this problem on their own.

The political feasibility of many of these policy proposals will depend on a number of factors, including public support and the political mobilization of reformers.  The political forces that oppose further – or any – regulation on guns have tended to prevail in the aftermath of previous mass shootings.  We believe in the possibility that, this time, things will be different.  We hope that the mobilization initiated by the Stoneman Douglas High School survivors continues to gain momentum.  Sustained engagement by reformers, both in advocacy and electoral politics, could turn the tide.

This post represents the opinion of the authors in their personal capacity and should not be construed as the official position of any agency, organization, or contractor by which the authors are presently or have been previously employed. 

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