Our American Sickness

We are broken in the United States.

We are number one in violent death (among high-income OECD countries)(1), opioid consumption(2) , and incarceration(3). We lag in life expectancy(4) , infant mortality(5) and healthcare equity(6).

In the wake of yet another school shooting, in which 17 innocent people were murdered by a 19-year-old with a gun, we find ourselves saying once again “Enough is enough”. With the Valentine’s Day Parkland shooting, the past five months have brought us three of the ten deadliest shootings in modern American history(7).

It is surreal to watch our mayors, our governors, our senators, our police officers, our district attorneys, our FBI agents, our children, our parents, our teachers, our superintendents all shake their heads in disbelief. We hear the familiar refrains of “How could this have happened in our school? In our city? In our state?” So familiar are these questions we might mistake them for the lingering echoes of the exact same questions we asked only days before. The fresh outpouring of “thoughts and prayers” engenders a sour resentment, the words are a well-intentioned but inadequate peroxide, stinging our national wounds.

It is surreal to watch another scared and shattered community attempt to make meaning of the devastation, to listen as they try to convey how deep, sharp, and breathtaking their pain is. Their harrowing experiences bring them into a growing community of mourners, branded by the all-too-common and all-too-American stamp of mass shootings.

Time and again we go through the grief and mourning algorithm that we’ve developed over the course of all of our school shootings and concert shootings and mall shootings and movie theatre shootings. It is especially baffling when we consider that galling lack of action over recent years in response to mass shootings. If the slaughter of 20 first graders in Newtown, CT couldn’t compel us to change, why on earth would anything else?

The calls to action I hear on the television or in the newspaper tell us that if we ‘see something, say something’, echoing the signage of airport security in the wake of acts of terror. We are encouraged to be more vigilant. We outfit our students with bullet-proof backpacks, our schools with armed guards and metal detectors. We drill our children with active shooter responses. We wring our hands wondering what else, if anything, can we do?

Often in these situations we hear our more conservative voices argue for restraint. After all, we ought to make decisions based on data. As student who has spent the past five years studying medicine and public health I tend to agree with this idea. Evidence based decision making should be encouraged, not emotional knee-jerk responses followed by reactionary policy. The problem is that data on strategies to reduce gun violence are profoundly limited.

The dearth of these data go back to a landmark article that was published in the New England Journal of Medicine in 1993 titled “Gun Ownership as a Risk Factor for Homicide in the Home” (8). The study demonstrated a strong association between gun ownership and the risk of homicide. In response to these findings, the Nation Rifle Association pushed for the wholesale elimination of the branch of the CDC responsible for this research. When that effort was not successful, the NRA in association with Rep. Jay Dickey (R-AR) worked to hamstring the CDC by stripping the $2.6 million allocated to funding gun research and by including language in a 1996 appropriations bill that stated 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.”(9) Eventually, near identical language was incorporated into the appropriation act for the National Institutes of Health. Decades later, following the Newtown Massacre, President Barack Obama signed a 2012 executive action that was to signal a turn in the tide. However, subsequent attempts to restore even modest funding for gun violence research were smothered in a stalemate congress.

It is in this context that the congressional calls for patience ring hollow and insulting. With our elected officials holding the purse strings of our government and crafting our national appropriations (and thus our national priorities), we have specifically and deliberately stymied our ability to study the problem of gun violence in the United States. The thirst for and dependence on campaign donations finds lawmakers clamoring to align their legislative obligations with those of their interest group donors. The National Rifle Association spent approximately $55 million in the 2016 election cycle alone(10). We need to have data informing our policies, not dollars.

Where does retired Rep. Jay Dickey stand now? In 2012, shortly after the shooting in Aurora, Colorado, he penned an op-ed in the Washington Post with Mark Rosenberg (who was the director of the branch of CDC that Dickey successfully defunded)(11). Together, Dickey and Rosenberg made an impassioned argument for a re-investment in the study of gun violence, stating “What is truly senseless is to decry these deaths as senseless when the tools exist to understand causes and prevent these deadly effects.”

I am in my final months as a medical student. Having spent many years in a seemingly endless loop between the hospital and the library, I am both eager and anxious to assume the trust, responsibility, and ethical obligations that come with being a physician. In this vein, I consider it an act of negligence to not advocate for the thorough and urgent study of the gun violence epidemic in the same way I would the opioid epidemic we currently face.

When I see patients — whether they are in the emergency department, hospital ward, or operating room — I try to use my knowledge, skills, and compassion to bring about healing. I do these patients a disservice if I do not consider and address the reasons they became ill in the first place. From a public health perspective, the same principle ought to be applied to our nation and its cancer of gun violence. It is past time that this societal plague be viewed as the true public health epidemic it is, and it is past time that we treat it as such. The American Medical Association and more than 100 other medical organizations agree(12).

Incredibly, it seems we remain ignorant to the fact that these events that we have become accustomed to are happening in only one country on the planet. What is it about the United States that makes us so unique in this regard? Many suggest that our mental health problems are to blame. Though if this truly was a mental health phenomenon, wouldn’t we expect to see higher rates of mental illness in the United States as compared to our peer countries? This is not the case(13).

What then could it be? Some have argued as recently as the day after the Parkland shooting that “Suggesting this is a mental health issue is a diversion. It’s an issue of not enough firepower to stop these killers.”(14) This proposal is further stoking of the fire that is the American arms race. In a country that represents 4.4% of the world’s population yet more than 40% of the worlds firearms, in land where we have more guns than people(15), I find this suggestion troubling. Can we seriously claim that we are lacking in firepower? I implore us to consider the evidence(16) that shows us that our mass shootings have something to do with the fact that we are awash with over 300,000,000 guns in this country.

Might it be that we are too uncomfortable with the notion that what it means to “bear arms” may have changed in the last 200 years though our laws have not?

We come back to the question of where to go from here. Our loudest voices might have us believe that there exists no middle ground between the status quo and a repeal of the 2nd amendment. If we turn down the inflamed rhetoric, we can hear a range of pragmatic voices that offer a different take. There are many smart ideas out there, allow me to suggest just three:

We ought to require a permit for the purchasing of firearms, an idea which is already law in 10 states and the District of Columbia. Studies of permit-to-purchase law show reduced rates of gun purchases being diverted to criminal hands, and that reversal of these laws have been associated with sharp increases in homicide-by-firearm rates, especially of law enforcement officers(17).

We ought to implement universal background checks on all gun purchases, a policy idea that is supported by a staggering 96% of Americans(18).

Finally, we ought to lift the federal floodgates on funding for research into gun violence. This would give our nation’s best and brightest scientists, clinicians, and researchers the resources to study this plague. It would also provide the evidence our policy makers and legislators so desperately need to begin crafting effective solutions.

These incremental steps will not prevent all shootings, but they will be steps forward. As I near becoming a physician I am acutely aware of the many difficult and painful conversations that lie ahead of me. However, during my time in medical school I have become convinced that often it is the hardest conversations that lay between hurt and healing. Let us not be dissuaded by the conversations we need to have. Let us avoid the trap of making perfection the enemy of progress. Let us harness our collective frustration and fury. It’s my belief that the next pages in the American story can be pages of healing. For this to be true we need to listen to the sober pleas of our nation’s children, like 17-year-old David Hogg, who gave our lawmakers a noble charge. “Work together to come over your politics, and get something done.”(19)

References:

1. Grinshteyn E, Hemenway D. Violent Death Rates: The US Compared with Other High-income OECD Countries, 2010. Am J Med. 2016;129(3):266–273. doi:10.1016/j.amjmed.2015.10.025.

2. Lopez G. The opioid epidemic, explained. Vox. https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses. Published 2015.

3. Walmsley R. World Prison Population List (tenth edition). Int Cent Prison Stud. 2013:1–6. doi:10.1111/j.1365–2362.2005.01463.x.

4. Etehad M, Kim K. The U.S. spends more on healthcare than any other country — but not with better health outcomes. Los Angeles Times. http://www.latimes.com/nation/la-na-healthcare-comparison-20170715-htmlstory.html. Published 2017.

5. Melorose J, Perroy R, Careas S. World population prospects. United Nations. 2015;1(6042):587–592. doi:10.1017/CBO9781107415324.004.

6. Dan Munro. U. S. Healthcare Ranked Dead Last Compared To 10 Other Countries. Forbes. 2014. https://www.forbes.com/sites/danmunro/2014/06/16/u-s-healthcare-ranked-dead-last-compared-to-10-other-countries/#256cac90576f. Accessed February 15, 2018.

7. Turkewitz J, Mazzei P, Burch A. Florida Shooting: Nikolas Cruz Confessed to Police That He Began Shooting Students “in the Hallways.” The New York Times. 2018.

8. Kellermann AL, Rivara FP, Rushforth NB, et al. Gun Ownership as a Risk Factor for Homicide in the Home. N Engl J Med. 1993;329(15):1084–1091. doi:10.1056/NEJM199310073291506.

9. Jamieson C. Gun violence research: History of the federal funding freeze. Am Psychol Assoc Psychol Sci Agenda. 2013:16–18. http://www.apa.org/science/about/psa/2013/02/gun-violence.aspx.

10. Schouten F. Why the NRA has so much clout in Washington. USA Today. https://www.usatoday.com/story/news/politics/2018/02/15/nras-big-spending-pays-off-clout-and-wins-washington/341257002/. Published 2018. Accessed February 15, 2018.

11. Dickey J, Rosenberg M. We won’t know the cause of gun violence until we look for it. The Washington Post. https://www.washingtonpost.com/opinions/we-wont-know-the-cause-of-gun-violence-until-we-look-for-it/2012/07/27/gJQAPfenEX_story.html?nid&utm_term=.0f5ff67d607f. Published July 27, 2012. Accessed February 15, 2018.

12. McCarthy C. Over 100 medical groups urge Congress to fund CDC research on gun violence | US news | The Guardian. The Guardian. https://www.theguardian.com/us-news/2016/apr/06/cdc-congress-research-gun-violence-public-health. Published 2016. Accessed February 17, 2018.

13. Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiol Psichiatr Soc. 2009;18(1):23–33. http://www.ncbi.nlm.nih.gov/pubmed/19378696. Accessed February 15, 2018.

14. Fox News. Twitter. https://twitter.com/FoxNews/status/964286006055833600. Published 2018.

15. Ingraham C. There are now more guns than people in the United States. The Washington Post. https://www.washingtonpost.com/news/wonk/wp/2015/10/05/guns-in-the-united-states-one-for-every-man-woman-and-child-and-then-some/?utm_term=.1c54b3b86570. Published October 5, 2015.

16. Fisher M, Keller J. No TitleWhat Explains U.S. Mass Shootings? International Comparisons Suggest an Answer. The New York Times.

17. Moyer M. 4 Laws That Could Stem the Rising Threat of Mass Shootings. Sci Am. November 2017. https://www.scientificamerican.com/article/4-laws-that-could-stem-the-rising-threat-of-mass-shootings/?utm_source=facebook&utm_medium=social&utm_campaign=sa-editorial-social&utm_content&utm_term=policy_news_text_resurface#.

18. Guns | Gallup Historical Trends. http://news.gallup.com/poll/1645/guns.aspx. Accessed February 16, 2018.

19. Rossman S. Florida school shooting survivor David Hogg: “We”re children’. USA Today. https://www.usatoday.com/story/news/nation-now/2018/02/15/were-children-you-guys-adults-shooting-survivor-17-calls-out-lawmakers/341002002/. Published 2018. Accessed February 17, 2018.