Gun violence research: Law, mental health, suicide, homicide.

Gun Violence Is a Public Health Problem: What’s Been Learned in the Past Three Years

Gun Violence Is a Public Health Problem: What’s Been Learned in the Past Three Years

Health and medicine explained.
Oct. 27 2015 11:15 AM

Gun Myths Die Hard

Research on gun violence has made progress in the past three years.

USA-SHOOTING/OREGON
A memorial honors the victims of the shooting at Umpqua Community College in Roseburg, Oregon, on Oct. 8, 2015.

Photo by Amanda Loman/Reuters

Every week, it seems, there’s another terrible incident in the United States involving a shooting. If the incident is horrendous enough—a mass shooting or a story about a child being slain or accidentally shooting another child—it is followed by a public discussion in which Americans ask, “How do we stop people from getting killed by guns?”

For Garen Wintemute, an emergency medicine physician and professor at the University of California–Davis, you answer this question the same way that you would if someone asked how to treat any of the most common conditions that bring people to an emergency room, such as chest pain, respiratory illness, or the flu: You look at the medical evidence.

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Wintemute has been studying gun violence since the early 1980s, inspired by Stephen Teret, a Johns Hopkins professor whose close friends lost a 21-month-old son. While the child was napping at the babysitter’s house, the babysitter’s 4-year-old grabbed his father’s handgun from a drawer and shot the baby through the head.

Teret and Wintemute co-authored a law review article that provided an evidentiary basis for suing gun makers who fail to use available safety technology to prevent accidental gun deaths. That article was later used in House of Representatives hearings on the rise of firearm violence and helped establish the principle that firearm violence should be treated as a public health problem. Wintemute concluded that prevention was the best way to stop gun deaths.

In 1987, he published a study in the Journal of the American Medical Association titled, “When Children Shoot Children: 88 Unintended Deaths in California.” His study found that, in about a third of the cases, the shooters didn’t even realize that the gun was loaded or real. Wintemute held a press conference to announce the results. When reporters showed up, they saw several guns like those that had killed the children in the study. Next to those guns were toy lookalikes. Few reporters could tell the difference.

Toy stores began pulling copycat toy guns from their shelves, and California later banned them.

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Today, Wintemute has published or edited more than 140 papers and books on gun violence. However, the field remains small. The National Rifle Association viciously attacks any medical research on guns and led a successful campaign in the 1990s to shut down gun violence research supported by the Centers for Disease Control and Prevention, cutting off $2.6 million a year for medical research.

Today, Wintemute is one of only a few dozen scientists who study gun violence, as many remain afraid of being targeted by gun activists or see little hope in entering a field where funding remains so low. Even discussing gun violence opens one up to attacks, such as a recent charge by a writer for National Review that the “mainstream media is dominated by people who have no experience with firearms.”

Shortly after the shooting at Sandy Hook Elementary School in 2012, I spoke with Wintemute for Slate about the lack of federal funding for research on gun deaths. Since that time, close to 90,000 Americans have died from guns. I contacted him again to talk about what has changed since our last interview and to dig more deeply into medical solutions to stop the killing.

After we spoke a couple years back, President Obama signed an executive action to end the ban on gun violence research. However, Congress writes the laws and recently extended the ban on CDC funding for these studies. What is going on with federal funding to study gun violence?

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CDC was never banned from doing research on firearm violence. The ban was on using federal funds “to advocate or promote gun control.” Research is not advocacy. President Obama recognized this and directed CDC to resume research. It has, but to my knowledge it has not relaunched its program of research by outside investigators.

The National Institute of Justice, however, has funded research on firearm violence almost continuously and is now focused on randomized trials of interventions to prevent such violence. And the National Institutes of Health, for the first time in its history, has a program of research specific to firearm violence. Private funders who have stayed the course since the 1990s have been joined by others in the past two years. Compared with three years ago, the situation is improved. Compared with what’s needed, the situation remains dire.

And what have we learned since our last discussion from published research?

We have updated and expanded our knowledge of the epidemiology of firearm violence and important risk factors for it. We have learned that mental health—or the lack of it—plays a minor role in criminal violence but is very important for suicide. That matters all the more because two-thirds of firearm deaths are suicides.

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We are learning about the importance of alcohol abuse as a risk factor for firearm violence. And we are learning more about the effectiveness of interventions such as requiring background checks for all firearm purchases. Several big studies now underway offer real hope for improvements in the future.

You recently published a review of the latest findings on gun violence. What questions and thoughts do you have when you see a patient?

There are pretty clear patterns of risk for firearm violence victimization, which are quite different for interpersonal violence (homicide and assault) and self-directed violence (suicide and attempted suicide). As I’m talking with someone, I think about how these patterns might apply to him or her.

At the individual level, we know about characteristics that increase risk for violence, such as alcohol and drug use. We also know that the presence of any one of those factors increases the chance that the others are present. And risk also increases as the number of those factors increases.

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These factors all build on one another. An older white male who is depressed; drinking too much; has a history of violence; and has loaded, unsecured firearms at home is in trouble. So are the people around him.

But the risk for both homicide and suicide is much lower for women than for men. At the same time, homicide risk is much higher for blacks than for whites. In fact, a young black woman is at greater risk of being killed by a gun than a young white male is.

The New York Times ran an awful story about guys in this Marine battalion coming back from war. They’re surviving combat but then coming home and killing themselves.

One guy shot himself in the head, realized he had only wounded himself, stepped in his bathroom, and then shot himself in the head again. So, he was serious.

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The broader picture is that veterans are at increased risk, in part because of their common access to firearms. It’s likely that there were signals in this man’s case that could have led to intervention. Firearm access is just part of the story, as we know. We’re still learning about the terrible effects that combat can have on survivors; we need to do a much better job of detecting and treating those effects.

The journal Nature ran a story a couple of years ago about you, pointing out that some physicians get worried when you speak at medical conferences. Why do doctors get worried when other doctors start talking about guns?

Lots of reasons. It’s not a traditional topic. It’s often not something they know much about. It brings up the uncomfortable fact that, while they believe they should talk to patients about firearms, they’re not sure what to ask or what to do with the answers. To be honest, relatively little research has been done—since funding has been so difficult to come by—and there often aren’t well-tested approaches to dealing with what is often a delicate topic.

But aren’t these doctors also worried about guns harming their patients?

Of course—at least we hope they are. But there are other things to worry about, too, and the importance of firearms as a risk factor will vary from patient to patient. Doctors may need to address smoking, and obesity, and much else. And they struggle with adding what might become a complicated discussion to an already crowded calendar for the day.

I’ve detected a change in the national discussion in recent months around guns. Reporters don’t seem as scared anymore of the NRA and are now talking about solutions to keep people from getting shot. Has the reporting changed, and is it getting better, or are reporters giving the public bad advice on the science?

I think the reporting’s gotten better. In particular, there have been in-depth investigations of specific topics by organizations like the New York Times, Washington Post, and others. My sense as someone who talks to reporters fairly often is that many are coming to understand that there has been a concerted effort to deprive the country of answers to important questions. In fact one of the architects of that effort, former Rep. Jay Dickey, has had a change of heart and has written that we need more research on firearm violence and the factors that lead to it.

David Hemenway at the Harvard School of Public Health just published an op-ed stating that there is a scientific consensus on guns: Gun laws reduce deaths, and putting more guns in the hands of people does not reduce crime. But myths to the contrary persist. What other myths are out there?

Probably the single most common myth is that easy access to a loaded firearm—in the home, for example—decreases your risk of a violent death. At the population level, the opposite is true. Evidence finds that access to a firearm increases one’s risk of being killed by a firearm. That’s a very well-supported statement these days.

There are two other particularly important examples, I think. First, people believe that firearm death is primarily a crime problem. Suicides with guns are more common than homicides, by far. Second, everyone thinks that criminal firearm violence is a mental health problem—that it’s people with mental illness who are shooting people. In reality, a history of violence, alcohol abuse, and even age and sex are more important factors.

At the same time, we need not to replace one myth with another. For example, there have been studies that have essentially toted up the number of laws various states have on the books and examined the association between the number of laws and rates of firearm death. That’s really bad science, and it shouldn’t inform policymaking.

Some laws work, and some don’t. The sad thing is that, because of a deliberate effort to prevent the research from being done, we don’t always know whether specific laws work or don’t.

One of the most common myths is the idea that arming citizens will stop mass shootings. Eugene Volokh of the University of California-Los Angeles School of Law recently found only 10 such cases since 1997. But it seems that whenever someone so much as waves a gun in the air when a crime is being committed, one of my relatives posts it on Facebook or I’m reading about it on Fox News.

Myths die hard. And remember, there’s money to be made here. If gun manufacturers can convince the public that it needs their products, they do better in the marketplace. The best example is the persistent myth I mentioned earlier, that having a gun in the home reduces risk of a violent death. We’ve all read of legitimate defensive uses of firearms, and ads for firearms repeatedly stress their use in defensive situations. But the science shows that at the population level, access to firearms is a risk factor for a violent death.

Yet there seems to be public resistance to medical professionals talking about guns. I’m reminded of the doctors and reporters in Africa who were actually attacked for trying to treat and report on Ebola. People in some parts of these countries are not familiar with basic biological concepts of disease transmission. Is there something similar to this cultural aversion to science happening here?

That resistance is overestimated. There is some good science on this, and the conclusion is that most patients are fine with firearm counseling, as long as the counseling is well-informed and nonjudgmental.

Science is only one factor we use to make decisions; other lines of information include economics, law, and politics. If we relied strictly on the science, what steps would we take today to reduce gun deaths?

I’ll stick to a few recommendations addressing firearms specifically. We should require background checks and record-keeping for essentially all firearm purchases. This proposal has very high levels of support from firearm owners, not just the general population.

Second, we should prohibit firearm purchases and possession for people who’ve been convicted of violent crimes. (That’s right: We don’t, except where the most serious crimes are involved.)

We should have similar prohibitions for people with multiple convictions for alcohol offenses like DUI. Lots of other good recommendations have been put forward by the Consortium for Risk-Based Firearm Policy.

What areas of research do we need to fund to improve policies and lower guns deaths beyond that? What questions need to be answered?

Research in this area has been intentionally stifled for many years. We need better information on what puts people at risk—and what keeps risk low. We need more rigorous evaluations of violence prevention policies. We need more comprehensive assessments of the effects of firearm violence on whole communities.

Look at it this way. There are more than 400,000 people buried at Arlington National Cemetery. Each one of those people made a great sacrifice, whether they died in combat or not. At current rates, we will fill another Arlington-sized cemetery with civilians who will die from firearm violence in less than 13 years.

The question we need to answer is: “Do we have the courage and commitment to mobilize and take action against firearm violence?”

I recently moved to Madrid from Washington, D.C. What has that done to my risk of being shot to death?

151022_MEDEX_Shooting-Statistics

Courtesy of Garen Wintemute, from “The Epidemiology of Firearm Violence in the Twenty-First Century United States” in the Annual Review of Public Health.

I don’t have data for cities. But Spain’s unadjusted risk of firearm-related death is less that 10 percent of that in the United States. In fact, we’re all by ourselves among Western industrialized nations in our risk of firearm-related death.