Tuesday, April 08, 2008

Guns Gone Wild: A public health perspective

An editorial (1) in the recent issue (April 2008) of the New England Journal of Medicine discusses two articles (2,3) in the same issue on the complex relationship between Handgun Violence, Public Health and the law. In the Cause of Death data for 2005 (the most complete recent data available; accessed April 8, 2008) published from the Disaster Center of the Centers for Disease Control and Prevention, 30,364 people in the United States died from firearm assault; a total of 17,002 of these were suicides, 12,352 homicides, 789 accidental firearm deaths, and 229 deaths from firearm discharges of unknown intent. Nearly half of these deaths occurred in people under the age of 35 (4). It has been estimated that every day in the U.S., guns cause the deaths of 20 children and young people under the age of 25 (5). Gun violence is a particular problem for the Black American community, which makes up 13% of the U.S. population, but in 2001 suffered almost 25% of all firearm deaths – and 52% of all firearm homicides (5). In Illinois, in 2005, Black Americans were victims in 429 (~42%) firearm-related deaths, of which 90% were homicides (5).

Consider, for a moment, the stupendousness and the implications of the data for 2005. All infectious diseases in the United States taken together caused about 2.7% of the deaths; in contrast, firearms alone resulted in 1.2% of the deaths. According to a CDC report on health statistics in 2003, firearm injuries are the second leading cause of injury-related deaths nationwide, surpassed only by motor vehicle injuries (6). Statistics released by the Bureau of Justice Statistics of the US Department of Justice show that in 2005 alone, 477,040 individuals including men, women and children were victims of gunshot injuries (7). Often injuries are fatal; in fact, more than 80% of gun-related deaths are pronounced dead at the scene or in the emergency department. It has been estimated that while about $2 billion is spent annually for medical care for the victims of gun violence, the estimated overall economic burden, including medical, legal and social, i.e. both material and intangible costs, is about $100 billion (8).

In his NEJM article, Mark Tushnet, a distinguised legal scholar from the Harvard University, reviews the current legal situation regarding the gun-control statutes (3). The point arises from a recent development.
On March 18, 2008, the U.S. Supreme Court heard oral arguments in District of Columbia v. Heller, a case challenging handgun-control statutes adopted in 1976 in Washington, D.C. banning further registration of handguns, carrying of concealed guns, and mandating that guns kept in residences remain unloaded and either locked or disassembled. The question before the Court is whether this ban violates citizens' rights guaranteed by the Second Amendment of the Constitution.

Apart from the public policy angle, it is also a question of constitutional law because of the Second Amendment, which states "a well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed", using ambiguous clauses that are subject to partisan interpretation.
According to gun-control advocates, the opening reference to a militia means that the right protected in the second clause is necessarily limited to keeping and bearing arms in connection with service in an organized militia, such as the Police force of a State. According to gun-rights advocates, the second part of the Amendment protects an individual right, no different in kind from the right of free speech protected by the First Amendment. In fact, interpreting the Second Amendment is a genuinely difficult task, precisely because we have to determine the relation between the first clause, sometimes called the Amendment's preamble, and the second, sometimes called its operative clause. The preamble could be a condition, limiting the scope of the operative clause, or it could merely be an explanation: "The reason people have an individual right to keep and bear arms is that it makes it easier to provide a militia as the security to a free state" (3).
Early in the Bush administration, the Department of Justice issued an extensive legal analysis supporting the gun-rights view of the Second Amendment. In the current context, it has modified its stance somewhat, holding that even if the Second Amendment protects an individual right to carry a gun, that right - like all others - can be regulated by the government for good reasons — as the Amendment's reference to a "well regulated" militia itself suggests — in the same manner as of the First Amendment, which allows the government to regulate speech only if it has extremely good reasons for doing so.

So, if it boils down to a question of finding a good reason, how about 'common sense'? GJ Wintemute, professor of emergency medicine and director of the Violence Prevention Research Program at the UC Davis School of Medicine, argues:
Gun violence is often an unintended consequence of gun ownership. Americans have purchased millions of guns, predominantly handguns, believing that having a gun at home makes them safer. In fact, handgun purchasers substantially increase their risk of a violent death. This increase begins the moment the gun is acquired — suicide is the leading cause of death among handgun owners in the first year after purchase — and lasts for years. The risks associated with household exposure to guns apply not only to the people who buy them; epidemiologically, there can be said to be "passive" gun owners who are analogous to passive smokers. Living in a home where there are guns increases the risk of homicide by 40 to 170% and the risk of suicide by 90 to 460%. Young people who commit suicide with a gun usually use a weapon kept at home, and among women in shelters for victims of domestic violence, two thirds of those who come from homes with guns have had those guns used against them (2).


Legislatures have enacted a radical deregulation of gun use in the community (2). Thirty-five states issue a concealed-weapon permit to anyone who requests one and can legally own guns; two states have dispensed with permits altogether. Since 2005, a total of 14 states have adopted statutes that expand the range of places where people may use guns against others, eliminate any duty to retreat if possible before shooting, and grant shooters immunity from prosecution, sometimes even for injuries to bystanders (2).

Click on the image for a larger image
State-Specific Firearm-Related Mortality per 100,000 Persons (2005) and Current Policies Regarding Expanded Use of Lethal Force and Permissibility of Carrying Concealed Weapons
[Data Source: Centers for Disease Control and Prevention, the National Rifle Association, and the Brady Campaign to Prevent Gun Violence. Photo courtesy Reference (2) in NEJM]

Two myths are propagated by vested interests in favor of personal gun use (2).

One is that increasing gun ownership decreases crime rates — a position that has been debunked in studies (9). Gun ownership and gun violence rise and fall together. Another myth is that defensive gun use is very common. The most widely quoted estimate, 2.5 million occurrences a year, is too high by a factor of 10 (10). Policies limiting gun ownership and use have positive effects, whether those limits affect high-risk guns such as assault weapons or Saturday night specials, high-risk persons such as those who have been convicted of violent misdemeanors, or high-risk venues such as gun shows. New York and Chicago, which have long restricted handgun ownership and use, had fewer homicides in 2007 than at any other time since the early 1960s. Conversely, policies that encourage the use of guns have been ineffective in deterring violence. Permissive policies regarding carrying guns have not reduced crime rates, and permissive states generally have higher rates of gun-related deaths than others do.

Washington, D.C., in 1976, acted upon the evidence and prohibited further registration of handguns, outlawed the carrying of concealed guns, and required that guns kept at home be unloaded and either disassembled or locked. These changes worked. Careful analysis linked them to reductions of 25% in gun homicide and 23% in gun suicide, with no parallel decrease (or compensatory increase) in homicide and suicide by other methods and no similar changes in nearby Maryland or Virginia (11). Homicides rebounded in the late 1980s with the advent of "crack" cocaine, but today the District's gun-suicide rate is lower than that of any state.

However, rational arguments employing common sense often fall into deaf ears, ably managed and encouraged by vested interests. Soon after the tragedy of September 11, 2001, some gun manufacturers were aggressively seeking new clients and new business. Ithaca Gun Company sold its Homeland Security model in the name of ''current time of national need.'' The Beretta gun company sold its ''United We Stand,'' a 9-millimeter pistol bearing a laser-etched American flag. The company sold 2,000 of them to wholesalers in one day in October, said Jeff Reh, vice general manager of Beretta U.S.A. The guns sold and bought ranged from small handguns to deadly assault weapons. Such proliferation of firearms, despite requirements for background checks, have been a major concern for those closely associated with the law enforcement agencies, because crime statistics shows that the same guns end up later in the hands of criminals or the deranged; also, more guns in circulation substantially increase the chances of violence in the home, suicide, or accidental shooting.

In 1992, 16-year old exchange student Yoshihiro Hattori was shot dead on his way to a Halloween party when he rang the doorbell of the wrong house. The perpetrator, Rodney Peairs, was tried for manslaughter. His lawyer summarized Peairs's defense as follows: "You have the legal right to answer everybody that comes to your door with a gun." A Louisiana jury acquitted him after 3 hours' deliberation. That state's laws now justify homicide under many circumstances, including compelling an intruder to leave a dwelling or place of business, and provide immunity from civil lawsuits in such cases. Thirteen other states have followed suit (2).

Many health care professionals recognize the familiar picture of gun violence in the gun-obsessed United States in such stories - a picture that includes the dozens killed and wounded this past year in a terrible series of mass-casualty shootings at educational institutions, shopping malls, places of business, and places of worship. Many of these innocent people were shot with guns that had been purchased recently and legally.

One wonders, how many more innocent people have to die, how many more families are to suffer terrible losses and tragedies, before this country finally wakes up to the brutal truth and eschews its crazed obsession with guns. Will it ever happen?

Source materials:

  1. GD Curfman, et al.,NEJM, April 3, 2008; 358(14):1503
  2. GJ Wintemute, NEJM, April 3, 2008; 358(14):1421
  3. M Tushnet, NEJM, April 3, 2008; 358(14):1424
  4. US Death Statistics, Table 10. (Access April 8, 2008)
  5. National Center for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System (WISQARS) Injury Mortality Reports, 1999-2005.
  6. National Center for Health Statistics, U.S. Centers for Disease Control and Prevention. National Vital Statistics Reports. Deaths: Final Data for 2003, Vol. 54, No. 13, p. 10, April 19, 2006.
  7. Bureau of Justice Statistics Report on Non-fatal Firearm related violent crimes, 1999-2005. (Accessed April 8, 2008).
  8. Cook PJ, Ludwig JL. Gun violence: the real costs. Oxford, England: Oxford University Press, 2000.
  9. Wellford CF, et al., eds. Firearms and violence: a critical review. Washington, DC: National Academies Press, 2004.
  10. Hemenway D. J Crim Law Criminol 1997;87:1430-1445.
  11. Loftin C, et al. NEJM1991;325:1615-1620.

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