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Forum: Doing Less Harm

David Hemenway advocates a public-health approach to gun homicides and suicides.

January-February 2020

An illustration of a handgun with bullets

Illustration by Gary Neill


Illustration by Gary Neill

The United States has far higher rates of firearm death than any of the more than two dozen other high-income countries (among them Australia, Canada, Germany, Italy, Japan, Norway, Spain, and the United Kingdom). In 2015, for example, children in the United States between the ages of five and 14 were 21 times more likely to be killed with a firearm—29 times more likely to be firearm-homicide victims, nine times more likely to kill themselves with firearms, and 20 times more likely to be killed unintentionally with firearms—than their peers in all the other high-income countries combined. I teach at a public-health school with many international students. They are appalled that Americans seem content to do little to reduce this carnage.

For decades, other injury-prevention experts and I have emphasized that gun violence in the United States is a major public-health problem as well as a public-safety problem, and that the country should use a public-health approach to help reduce the problem. These two claims have been fought by the gun lobby.

In the 1950s, motor-vehicle manufacturers promoted the idea that if only drivers never made mistakes and never disobeyed the law (e.g., drove fast or drove drunk), there would be hardly any crashes or traffic deaths. And they were right. They were thus able to focus public policies on the driver: promoting mandatory drivers’ education and enforcing traffic laws. 

Fortunately, public-health physicians began asking a different question: not “Who caused the crash?” but “What caused the injury?” Drivers were being impaled on unyielding steering columns; their faces were being ripped apart by windshields not made of safety glass; they were being thrown from their cars, their heads hitting the car hood or the street; or vehicles that left the road hit trees and lampposts deliberately placed along the sides of highways. The public-health physicians asked why the cars and roads couldn’t be made safer, why the Emergency Medical System (EMS) couldn’t be improved. Fast forward half a century: no one thinks that drivers overall are any better today than they were when I first learned to drive. (They are better about drunk driving, but worse about distracted driving.) But the cars and roads are much safer, the Emergency Medical System is better—and fatalities per mile driven have fallen more than 85 percent. This is a major public-health success story. 

Today, the gun lobby wants policy to focus solely on the shooter. After all, if no one ever got angry, scared, or depressed, if no one ever made a mistake or acted irresponsibly or criminally, there would be hardly any gun injuries. Just as the twentieth-century motor-vehicle lobby wanted to deflect public attention from the motor-vehicle industrial complex, so the gun lobby today wants to keep policy attention away from the firearms industry.

 

The public-health approach to problems focuses on harm reduction. Public-health practitioners assumed, for example, that motor vehicles would be widely used into the foreseeable future, so their goal was prevention—how to reduce the number of serious injuries and deaths. As is usually the case, it turned out that the most cost-effective measures for prevention occurred far upstream, and that it was—and is—a terrible mistake to focus exclusively on the single individual with the last clear chance for prevention: the driver (or the shooter). 


Illustration by Gary Neill

Too often the first thought of most people, when injury occurs, is to determine whom to blame. But blame is often counterproductive for prevention; if someone else is at fault, there is little reason for others to help in prevention efforts.

Rather than rely on the blame game, the public-health approach to reducing gun violence seeks to bring people and institutions together to get to work on the problem. It invites everyone to join the effort as part of the solution. It wants all groups—including law enforcement, medical providers, the faith community—to continue to perform their regular duties in helping prevent firearm injuries, but it also wants them to focus more on prevention in their routine activities, and to go outside their comfort zones. For example, public-health practitioners want police not only to enforce laws, but to enforce them in ways that are most likely to prevent future problems. Practitioners also applaud police officers who go out into the community to promote better law enforcement-community relations. Boston police, for example, have social workers in most precincts, and an ice-cream truck that provides treats for city residents. The faith community in Boston not only preaches about morality, but played a direct role in the 1990s “Boston Miracle,” when youth firearm deaths fell more than 60 percent. Religious leaders united, worked together with law enforcement and the community, and were often conspicuously present on the streets where and when the worst violence occurred. 

There are so many things that institutions (and individuals) can do to reduce the nation’s firearm-related public-health problems. Firearm manufacturers could reduce gun accidents by ensuring that semi-automatics cannot shoot when the magazine is removed; they could reduce gun theft, gun accidents, and gun suicides by producing “smart” guns that can be used only by the owner and others authorized by the owner. All gun shops could begin using “best practices” for preventing straw purchases (as some alcohol retailers have done to reduce underage alcohol purchase). Gun owners could store their firearms safely to reduce accidents and theft: it is estimated that more than 300,000 guns are stolen each year, a main way these weapons get into the wrong hands.

Focused conversations can be helpful. Even though members of gun-owning households are about 50 times more likely to commit suicide with a firearm than to die from an unintentional shooting, and far more likely to die in a firearm suicide than in a firearm homicide, most firearm instructors never even mention suicide. My colleague Cathy Barber has had success working with gun shops, gun ranges, and gun trainers to reduce suicides by promoting the message that, just as “Friends don’t let friends drive drunk,” friends should offer to “babysit” the guns of someone going through a rough patch, until things get back to normal. This is one way to reduce suicide without any new laws—or even attempting to change anyone’s mental health. 

Many other groups could help as well. Healthcare providers could help families get guns out of a home when someone in the household is at risk for suicide. Insurers could offer lower premiums to gun owners who store guns safely. Consumers could boycott companies that engage in practices that most endanger public safety, such as promoting firearms and accessories, like bump stocks, that increase deaths in mass shootings. Media in metropolitan areas could focus less on individual shooters and more on how and from where their guns were brought into the city. Foundations could again financially support firearm research and data collection (two decades ago, foundations provided the funds to create the pilot for the National Violent Death Reporting System). Once these groups, and many others, are energized to help tackle U.S. gun violence, they almost always find innovative and effective approaches for reducing the problem.

 

The federal government itself has many ways to help reduce firearm injuries. For example:

Data and funding: In the motor-vehicle arena, the National Highway Traffic Safety Administration created excellent data systems (for example, the Fatality Analysis Reporting System that provides detailed information on the circumstances of every motor-vehicle fatality) and provides funding for research. As a result, investigators know the types of policies that should reduce motor-vehicle injuries, and can evaluate whether they are in fact working. But for firearms, there have been deliberate and successful attempts to reduce data collection and data availability, and to limit government funding of research. It has thus been difficult to determine what is actually going on regarding firearms, and whether existing policies are effective. The lack of data and research allows nonscientific claims to gain standing, because there is little science to support or disprove them.

Research and purchasing: The Air Force built the first major motor-vehicle safety-testing facilities in the United States, providing crucial scientific information on car safety. The General Services Administration purchase of airbags for its fleet was instrumental in demonstrating that airbags save lives—allowing for the mandating of airbags in all automobiles. Similarly, government research on, and its purchase of, “smart guns” that help prevent unauthorized firearm use could reduce gun theft, gun accidents, and gun suicide.

Standards: The research on and promotion of standards by the National Institute of Standards and Technology (NIST) for the fire-safety of cigarettes enabled states to mandate that cigarettes meet designated performance standards, thus reducing the incidence of cigarette-caused fires. Similarly, NIST could help write safety standards for firearms—leading to requiring, for example, child-proof firearms that, like child-proof aspirin bottles, could reduce unintentional deaths among toddlers. (Unlike other age groups, toddlers typically shoot themselves; indeed, the unintentional firearm death rate for toddlers is currently higher than that for five- to 10-year olds.) 

Knowledge dissemination: The U.S. Surgeon General reports on the dangers of cigarettes helped reduce smoking and thus the cancer, heart disease, and other health problems it caused. Similarly, Surgeon General reports on the overwhelming scientific evidence demonstrating the connection between a gun in the home and completed suicide could help reduce firearm suicide, and the overall suicide rate.

Taxes and subsidies: Cigarette taxes have helped reduce smoking among youth, and taxes on sugar-sweetened beverages can reduce obesity. Differential taxes on different types of firearms (e.g., “assault weapons”) could help reduce the stock of those firearms most effective in killing large numbers of victims quickly. 

Regulations, monitoring, and enforcement: Licensing of drivers and registration of motor vehicles have helped reduce motor-vehicle injuries and thefts. Laws regulating the purchase of cigarettes and where smoking is permissible have helped reduce cigarette-caused illness. Similarly, federal, state, and local governments write and enforce many types of firearm regulations pertaining to background checks, training, storage, gun carrying, and where guns can be fired. 

The scientific evidence indicates that, all other things equal, places with stronger firearm laws have fewer gun problems and suffer fewer violent deaths than places with weaker laws. The existing evidence about which of the many individual laws are most effective is less compelling, but I believe that national firearm-licensing laws, handgun registration, and a requirement of strict liability for firearms owners would substantially reduce firearm violence. (Virtually every gun in the United States begins as a legal gun: manufactured legally and sold to someone who did not fail the federal background check. Yet many guns get into the hands of people who almost everyone agrees should not have them, often through theft. By shifting the burden of proof, strict liability would provide better incentives for owners to protect their guns from improper access.) 

Far more households own motor vehicles than own guns. Yet firearms kill about the same number of civilians as do motor vehicles....We need to do a much better job of learning to live with our firearms. Currently, far too many people are dying.

 

Motor-vehicle injury prevention is many-faceted, involving: pedestrian, bicycle, and motorcycle injuries; injuries from roll-overs and from side-impact and head-on collisions; and deaths from vehicle fires. Thus, not surprisingly, the successful reduction in the motor-vehicle death rate per mile traveled did not come from one or two policies or programs, but from many. For example, collapsible steering columns helped reduce injury to drivers in frontal collisions, but did nothing to protect passengers, pedestrians, cyclists, or even drivers in side-impact crashes. Similarly, firearm policies, such as a standard to prevent dropped guns from firing, could reduce accidental injuries, but would do little to reduce homicide or suicide. We need many reasonable policies and programs to help reduce our firearm-related public-health problem. 

There are hundreds of millions of motor vehicles in the United States, and hundreds of millions of firearms. Motor vehicles (cars and trucks) are crucial to our economic well-being, and far more households own motor vehicles than own guns. Yet firearms kill about the same number of civilians as do motor vehicles. Historically we have had some success in learning to live with motor vehicles. We need to do a much better job of learning to live with our firearms. Currently, far too many people are dying.    

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