A public health perspective on gun violence prevention

Gun violence is a public health problem. Each year in the United States, tens of thousands of people are killed by gunfire and many more are seriously injured with resulting disabilities.1 Among the victims of gun violence are curious young children who encounter loaded guns and do not understand the damage they can cause; depressed teenagers who commit suicide; victims of domestic abuse; and the casualties of many other violent crimes. For some population groups, death by gunfire is the number one cause of death. It has been estimated that the lifetime medical costs of gun violence that occurred in the single year of 1994 was approximately $2.3 billion,2 a huge sum of money that could be better spent on solving other societal ills. Whether measured by mortality or morbidity statistics, by cost to society, or by sheer grief and disruption to the population, the toll of gun violence is too high, and it places the public's safety at unacceptable levels of risk. Interventions are needed to address this public health problem. Although guns and gun violence have long been a part of American life,3 it is only in the past few decades that guns and gun-related injuries have come to be seen as a public health issue. In the past, gun-related homicides were viewed as a problem to be solved by law enforcement and the criminal justice system. Gun-related suicides were problems belonging to the discipline of mental health. The comparatively small numbers of unintended gun deaths were seen as within the province of hunter safety courses or other educational programs for accident prevention. With the blossoming of the field of injury prevention within the discipline of public health, a field that only came into general recognition in the 1970s, researchers, practitioners, and advocates began to recognize the toll that guns take on the public's health. Instead of having a fractionated view of gun deaths by separately considering homicides, suicides, and unintended gun deaths, articles began to appear in health journals that aggregated all gun deaths.4 When gun deaths were combined, based on the reasoning that all of the deaths involve the same vehicle (i.e., a gun), it was realized that guns form the second leading cause of injury death in the United States, surpassed only by motor vehicle-related deaths.5 As previously noted, for some segments of the population such as young African American males, gun-related deaths are the leading cause of deaths overall.6 The aggregation of all gun deaths, simple as that sounds, is an idea that is quintessential to the public health method of thought and therefore an idea that was dormant until those in the field of public health addressed their attention to guns as a health problem. Public health has a tradition of looking beyond the individuals inflicted with injury or disease. The physical and social environments in which human damage occurs, and, importantly, the vehicles or vectors that deliver the agents of injury or disease, are all considered part of the causation of morbidity and mortality and therefore possibly part of the solution to reducing the incidence of morbidity and mortality. Public health researchers and practitioners recognize that changing the behaviors of people involved in the causation of injury and disease is a potentially effective approach but one that is difficult to achieve. Changing the man-made products that are associated with injury and disease can sometimes be more easily accomplished than changing the behaviors of those who use the products. This has been the case with automobiles. After many years of trying to raise the skills of the driving public, it was realized that cars and highways could be redesigned so that, when the foreseeable crash occurs, the vehicle occupants do not have to suffer fatal injuries. Seatbelts, energy-absorbing steering columns, air bags, and breakaway road signs have all helped to save hundreds of thousands of lives that otherwise would have been lost in crashes.7 Similarly, although gun injuries are often the result of troublesome behaviors involving rage, depression, and carelessness, and are compounded by social ills such as poverty and discrimination, there may be interventions available to reduce gun-related deaths that do not focus solely on modifying individuals' behaviors. But most gun policies prior to the past two decades addressed individuals' behaviors, and often those individuals were already in possession of guns, resulting in reactive rather than preventive policy strategies. The initial recognition that guns were involved in a great many deaths in the United States fell short of the formulation of sound prevention policies to address this public health risk. In 1980, an article was published in the Journal of Public Health Policy that suggested for the forst time that gun policy might be more effective if it focused less on the behaviors of shooters and more on the product itself.8 The article (and other articles following it)9 postulated setting policy priorities categorized according to a fictional life span of a gun. The suggestion was made that the manufacture of a gun is analogous to its birth and that other milestones in the life span of the gun include its sale, possession, and use. Most policy was directed toward the end of this life span-the use of the gun. The suggestion was made that for policy to be most effective, with effectiveness being defined as producing a reduction in the incidence of gun-related deaths and injuries, the focus of policy should be shifted backward in time along this fictional life span. The most effective policies might be those that regulate the design and marketing of guns. This public health perspective on gun violence prevention achieved rapid and widespread acceptance within the health and medical communities. Healthy People, the U.S. surgeon general's report on the nation's ten-year health goals to be achieved by 1990, recognized that firearms were claiming tens of thousands of lives each year. In discussing health protection strategies, the report stated: "Measures that could reduce the risk of firearm deaths and injuries range from encouraging safer storage and use to a ban on private ownership."10 The public health literature on the epidemiology of gun violence and the policies to reduce it blossomed in such leading medical journals as the Journal of the American Medical Association and the New England Journal of Medicine. The descriptive epidemiology of gun violence was fully explored, and some hypothesistesting research on topics such as the risks of gun ownership was reported. Additionally, the new literature began to include scientific evaluations of policies designed to reduce the incidence of gun violence. By 1988, James Mercy and Vernon Houk of the federal Centers for Disease Control and Prevention (CDC), in a call for continued scientific investigation of firearms as a public health problem, delineated four steps needed "for further research and the development of effective strategies to prevent firearm injuries."11 These steps involved the determination of the size, characteristics, and cost of the problem; the determination of the number, type, and distribution of firearms in the United States; the further development of hypothesis-testing epidemiologic research; and the rigorous evaluation of regulations and other interventions that affect the risk of firearm injury. More studies followed these suggestions, and by the early 1990s a body of evidence existed indicating that firearms were a leading public health problem and that policies to address the problem were both needed and feasible. Around the same time, however, a concerted attack against the public health community's efforts to reduce gun violence was mounted. In a 1995 article by Don Kates and colleagues, published in the Tennessee Law Review, it was suggested that the public health literature on gun violence was created by academics who "prostitute scholarship, systematically inventing, misinterpreting, selecting, or otherwise manipulating data to validate preordained political conclusions."12 In addition, the National Rifle Association (NRA) was critical of efforts to frame gun violence as a public health issue and led the campaign to end gun violence prevention research funded by the CDC.13 In 1992, Congress established the National Center for Injury Prevention and Control (NCIPC) in the CDC with the mission to reduce injury-related morbidity and mortality.