Guns: Lessons for addressing obesity from a public health approach to gun violence
Friday, January 09, 2004The purpose of this memorandum is to review the history of the public health approach to gun violence prevention, with a focus on certain aspects of firearm policy-making in the United States, so that it can be determined whether there are lessons to be learned from those experiences that will relate to policy changes regarding nutrition and obesity.The shift from behavioral approaches to policy approaches to reduce gun violence
Guns have long been prevalent in American culture and have taken a heavy toll in morbidity and mortality, but gun violence was not seen as a public health issue until relatively recently. Traditionally, gun violence was viewed as involving crime or mental health problems, and most interventions to reduce gun violence focused on altering the behaviors of maladjusted people. There are several reasons for the delayed recognition of gun-related injuries as a public health problem. First, the scope of the problem was masked because the number of gun related deaths was traditionally fractionated among homicides, suicides, and unintended deaths; i.e., only in the past few decades did researchers aggregate all gun deaths in providing the descriptive epidemiology of gun mortality. Second, it was generally believed that the approaches to reducing gun deaths were wholly dependent upon and different for the specific intents associated with the deaths (homicidal, suicidal, and unintentional). There was no realization that firearm policies to reduce homicides might also affect suicides and unintended deaths. Third, the field of injury prevention within the discipline of public health did not mature until the 1970s, and therefore, modern understandings of the theoretical underpinnings for gun violence prevention were delayed until that time. Beginning about 1980, the field of injury prevention recognized that guns were the second leading cause of injury deaths in the United States (surpassed only by motor vehicle-related deaths), and that a focus on the product associated with all of these deaths might aid in prevention. This is one of the great contributions of the fields of public health and injury control. Rather than relying solely on changing the behaviors of those at risk of injury or disease, public health looks at the agents, vehicles and vectors associated with morbidity and mortality, as well as the social and physical environments. Public health realizes that it is often insufficient to exhort people to be careful in avoiding risks. If you want to reduce the incidence of water-borne cholera, consider removing the pump handle from a contaminated well in addition to asking people to boil their water. If you want to reduce highway fatalities, make cars crashworthy so that when the foreseeable crash occurs, the decelerative forces on the car's occupants are managed at non-fatal levels, as well as asking people to drive more carefully. If you want to reduce gun-related deaths, formulate policies that address gun design, distribution, and possession in addition to trying to manage anger and depression among the gun-toting population. It was also discussed for the first time in the early 1980s that gun policies would likely vary in their effectiveness depending upon what aspect of guns were addressed by the policy. A suggestion was made that we think of a gun as having a "lifespan" with several important stages in that lifespan that could be the foci of policy efforts to reduce gun violence. Those stages are the "birth" or manufacture of the gun including decisions made about its design, the sale of the gun, its possession (or carrying), and finally its use when the trigger is pulled. While most gun policy at the time addressed the last of these stages, the suggestion was made that policy would be most effective in preventing gun-related deaths if the policy focus was shifted back to the early stages of the gun's lifespan. It should be easier to control the design of the gun than to control the behaviors of millions of people into whose hands new guns are placed every year. And by controlling the design of the gun (perhaps by legislation, regulation, and litigation), deaths can be averted. Guns can have more safety devices, such as loaded chamber indicators and magazine disconnect devices, and guns can be made so that they are operable only by authorized persons. Curious toddlers or depressed teenagers who find a gun in their homes should not be able to discharge the gun. The half million guns that are stolen each year in the United States in home burglaries would be inoperable by the thieves, if the design of guns was controlled by meaningful policies. In a relatively short period of time, the nation's approach to preventing gun violence was materially changed, with guns being seen for the first time as household products that needed to be regulated for the public's safety. It was recognized that our nation's problem with gun violence involved not only the person pulling the trigger, but also, importantly, the person making the trigger. While this sea change in perception held out great promise for the reduction of gun violence, mighty oppositional forces (discussed herein), some of which were inadequately anticipated, have somewhat limited or delayed the positive effects of this new approach.The research that has been needed to reduce gun violence
Several types of research have been of critical importance to gun violence prevention efforts. Initially, the descriptive epidemiology of gun-related mortality had to be developed, and high risk groups and circumstances had to be identified. Data on gun-related morbidity was much more difficult to acquire, and studies examining non-fatal injuries followed far behind the mortality studies. International comparisons of gun death rates were developed. Next, hypothesis testing epidemiological research was needed to answer basic questions such as whether having a gun in the home was, on balance, protective or perilous to those living in the home. This type of research was far more difficult to accomplish, and attracted considerably more criticism than the descriptive research. Survey research, that sought answers to questions regarding gun possession and storage, and the public's opinions on existing and proposed gun policies was undertaken. Analyses of the effects of policies, such as the evaluation of specific gun control laws, were performed. Legal research on the constitutionality of gun regulation, and the documentation of the many federal, state and local gun laws with their effective dates was accomplished. For each of these phases of research, there was and still is substantial opposition as to the need for such research, and the integrity of the researchers as well as the validity of their findings. Accusations of outright, intentional falsification of findings have been made frequently and publicly of gun researchers. A campaign to strip the Centers for Disease Control and Prevention (CDC) of its injury control funding as a punishment for its involvement in gun research was in part successfully made in Congress. Only recently has CDC been able to re-engage in substantial data collection that will ultimately provide information on the circumstances and products involved in violent injuries. The absence of this information has hampered the development of evidence-based policies for the prevention of gun violence. Researchers who are generally viewed as ideologically aligned with the politics of pro-gun organizations have produced hotly contested but widely publicized research findings that describe the benefits of gun possession. Much effort by public health researchers has been devoted to assessing the validity of this work. All in all, in the field of gun violence prevention, given the well organized efforts of pro-gun organizations and individuals, the relationship between research and policy enactment is probably more tenuous than for other public health issues. Much of gun policy is based more on rhetoric than on research. Nevertheless, without the public health research on gun violence of the past 25 years, we would probably now be experiencing significantly more gun deaths than presently exist, because gun policy would be even less well informed and less effective.Policies that contribute significantly to reducing gun violence
There has been a substantial reduction in gun mortality in the United States between the mid-1990s and now. Much of this has taken place among gun homicides; but gun suicides, which represent the greatest share of gun deaths, have not experienced a decline of similar proportions. Unintended gun deaths, which represent a small percent of all gun deaths, have been significantly declining for many decades. The causes of such declines are not clearly known. Much has been written on the relationships of gun deaths (particularly homicides) to illicit drug trade, to the nation's economy, and to the decay of traditional values. There is some research that relates the decline in gun deaths to specific gun policies, such as bans on certain types of guns, and other restrictions on the sale of guns. Some proposed gun policies, such as those dealing with the design of guns, have not had widespread enough enactment or implementation to allow for the scientific assessment of their effects. The challenges of evaluating the effects of gun policies are great. There is inadequate funding to support sophisticated research, there are problems with controlling for the many variables that might affect levels of gun violence, and there are social disincentives for young researchers to dedicate their careers to gun related research. The field of gun policy evaluation is still young, and the understandings of what policies work best to reduce gun violence are still incomplete.False starts, dead-ends and other problems with gun research and policy
The field of gun violence prevention, probably more so than is the case with other public health endeavors, is beset with internal disagreement and failure to cooperate among its strongest and most visible organizations and individual practitioners. This, accompanied by scarce resources and a powerful and well organized political opposition to gun control, has severely limited the successes of gun violence prevention. One false start of note for gun violence prevention has been the involvement of grass roots organizations. Much of the history of gun control has been dominated by warring advocacy groups located in Washington, D.C. Controversies regarding the sought endpoints of gun policy, ranging from a ban on all handguns to much less restrictive policies, have consumed the energies and assets of these groups while other organizations, such as the NRA, seem to enjoy clearer policy goals and better access to policy makers. But a few years ago, there arose a grassroots organization called the Million Mom March, that attracted the attention of the nation by a highly visible march in Washington, D.C., coordinated with similar events across the country. It appeared that advocacy for gun violence prevention had taken a turn, and that the voices of many who have suffered the tragedy of gun violence would finally be heard, with a chance to materially affect gun policy. But those voices were not sustained. They were silenced by bickering among the various traditional and newly emerged gun control groups, each trying to assert some level ownership and control over what seemed to be a breakthrough in advocacy for gun violence prevention. The loss of momentum caused by an inability to cooperate and an inability to seize the remarkable opportunity for a common good was a major setback and a false start. Another partial false start has been in the area of gun litigation. For many years, a small group people worked hard to prepare the soil that would ultimately foster litigation against gun makers as an effective tool in reducing gun deaths. It was thought that we could accomplish through strategically placed lawsuits what we have been unable to accomplish through federal legislation and regulation, due to the strength of the NRA's influence on national politics. But before the necessary preparatory work could be finished, litigation brought by municipalities was prematurely initiated, perhaps for expected political and personal gain, with the outcome being that ill-advised lawsuits have been dismissed, setting precedents that will now be difficult to overcome. The work that should have been completed before the initiation of the lawsuits deals with supportive scientific research findings, expert witness development, and sophisticated legal research on theories of liability. Perhaps the most serious problem caused by these premature lawsuits is the likelihood that Congress will grant the gun industry an immunity from almost all gun litigation, thus removing from the field of public health what might have been its most effective tool in reducing gun violence. Lastly, the "mighty oppositional force" previously referred to is the NRA. More than any other entity on either side of the gun violence prevention issue, the NRA dominates the conversation and action on gun policy. As a powerful and wealthy organization dedicated to the twin missions of increasing the prevalence of guns in the United States and decreasing any government involvement in the regulation of guns, the NRA develops legislative strategies of its own to further its mission and anticipates strategies of the gun violence prevention movement so that those efforts can be blocked. The NRA has met with considerable success. Its members and officers are dedicated to the organization's cause and are willing to work hard, spend considerable amounts of money, play hardball politics, return to lost campaigns, and ultimately punish those who see the world differently from them. The NRA also has substantial control over the major gun manufacturers, and is willing to exert that control to keep the manufacturers from breaking rank by, for example, making safer guns. Beyond the NRA, there are organizations and individuals who take even stronger positions regarding policies for and the advocates of gun violence prevention. Many of the more prominent persons in the field of gun violence prevention have experienced death threats over time for the work that they do.Specific advise, based on the above, for those working to prevent obesity
Some of the situations and problems described above are peculiar to gun violence prevention, and therefore do not provide lessons for the prevention of obesity. Other aspects of the gun violence prevention movement, however, may shed light on fruitful paths for obesity prevention. Included among the lessons to be learned are these:- While scientific research is, in itself, inadequate to control the enactment of policy (because other factors such as politics play a more central role), research remains a necessary but insufficient element of policy formulation.
- nticipate the political and scientific opposition to your policy goals, and begin immediately to address that opposition.
- Seek, to the greatest extent possible, apparent if not real agreement among those working for obesity prevention.
- Use litigation against food makers and distributors when advisable, but be sure that you have secured the scientific studies and other evidence you need as evidence in court, that the legal theories have been well researched, and that you have available the experts who are willing to testify in court, before you initiate litigation.
- Work as hard as possible to assure adequate funding for your efforts by foundations and other sources who will commit to a long term effort.
- Work with the media to gather public opinion supportive of your efforts, and measure that public opinion through survey research.
- Be willing to measure success over a period of decades, rather than expecting a win within a few years.