Just about the only thing that everyone agrees on when it comes to gun violence is that it’s a problem in the US. The numbers are sobering:
Those countries all also enjoy low rates of gun violence, but the U.S. has the 31st highest rate in the world: 3.85 deaths due to gun violence per 100,000 people in 2016. That was eight times as high as the rate in Canada, which had 0.48 deaths per 100,000 people — and 27 times higher than the one in Denmark, which had 0.14 deaths per 100,000.
The countries with a higher rate of gun deaths tend to be war torn, or failed states with powerful criminal organizations. In 2016 in the US there were 15,592 deaths involving guns (not including suicides, which average around 22,000), including 346 mass shootings, 732 children, and 3,234 teens.
And that is where any significant agreement ends, on the raw numbers. Significant majorities of Americans agree with certain measures, such as background checks and banning certain accessories, like bump stocks which allow semi-automatic weapons to fire more like a fully automatic weapon. But for various reasons these majorities do not translate into political will.
There is wide disagreement about the causes of our out-of-proportion gun violence and what measures will have a beneficial effect. This is not unusual – there is wide disagreement about most important issues. One way to see our way through conflict and paralysis is with objective scientific information. This will never convince the true-believers (witness anti-vaxxers) but can marginalize them and empower the evidence-based majority to take action.
What I want to discuss here is not what the current scientific evidence says (that is a complex topic for another post), but simply advocate for doing scientific research on gun violence in the first place. If ever there were a debate that needed an injection of objective facts, this is it.
The Dickey Amendment
As summarized in a recent JAMA article:
A 1996 congressional appropriations bill stipulated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention [CDC] may be used to advocate or promote gun control.” Similar restrictions were subsequently extended to other agencies (including the National Institutes of Health), and although the legislation does not ban gun-related research outright, it has been described as casting a pall over the research community.
What Congress did was reduce the CDC budget by the exact amount spent on gun violence research. This was clearly intended to intimidate the CDC by directly threatening their funding. The tactic worked, the CDC got the message, and effectively all research into gun violence at the CDC stopped. The JAMA article also researched the results of this policy:
Compared with other leading causes of death, gun violence was associated with less funding and fewer publications than predicted based on mortality rate. Gun violence had 1.6% of the funding predicted ($1.4 billion predicted, $22 million observed) and had 4.5% of the volume of publications predicted (38 897 predicted, 1738 observed) from the regression analyses. Gun violence killed about as many individuals as sepsis. However, funding for gun violence research was about 0.7% of that for sepsis and publication volume about 4%. In relation to mortality rates, gun violence research was the least-researched cause of death and the second-least funded cause of death after falls.
Some have argued that the CDC (Centers for Disease Control) has no business researching gun violence because being shot is not a “disease.” This argument does not hold water, however, and seems deliberately concrete. The CDC researches all threats to the health of Americans, and being shot dead is a significant risk to health. The CDC also researches deaths from car crashes, and how to mitigate those deaths, for example. And as stated above, the restrictions on research extend to other agencies, like the National Institutes of Health.
Gun violence is estimated to cost $229 billion dollars a year to our society ($8.6 billion in direct costs and the rest from indirect costs). Reducing gun violence is therefore likely to be cost effective, and certainly a cost of this magnitude to our society warrants proportionate research.
A recent national survey finds that 55% of Americans support research into gun violence. While it is good that a majority supports research, it is a disconcerting that 45% of Americans do not support researching gun violence.
The scope of medicine
The fact is that all forms of injury and trauma are considered well within the scope of medicine, uncontroversially so. Doctors, and by extension those involved with public health, consider all risk factors and threats to health. This includes many things that have nothing to do with disease, but relate to safety from violence or trauma.
Parents cannot take their newborn infant home until they demonstrate that they have a proper car seat. We know what constitutes a proper car seat from research into the effects of various designs and behaviors on the risk of death or injury from an accident.
Physicians must also consider the role of domestic violence in the presentation of their patients. Physicians are encouraged, for example, to ask as a routine question, “Do you feel safe at home.” We are trained to look for signs of domestic abuse and to protect vulnerable populations.
Taking a thorough history from a patient can be very intrusive – we ask about their diets, their daily habits, their relationships, their home situation, their socioeconomic situation, their personal and intimately private behaviors, even behaviors that are illegal. We do this because all of this information is potentially important to the health of our patients. We also do it within a professional covenant that we will use that information only for the benefit of our patients, and with the strictest confidence (legally protected privilege).
Why, then, should gun use, or the presence of a gun in the home, be singled out for special exception? Yet in 2011 Florida passed a law prohibiting doctors from asking their patients about access to guns in the home. This law was recently struck down by a federal appeals court for violating the first amendment rights of doctors.
We shouldn’t fear information
There are some clear steps we can take together as a society. Doing basic research into a clear problem, with resources proportional to the size of the problem, should be uncontroversial. The Dickey Amendment should simply be repealed. Even Jay Dickey, before he died, regretted sponsoring the Bill:
Dickey, the congressman responsible for the amendment suppressing the CDC’s gun violence research, passed away last April. He had come to regret his role in the episode. In 2012, he coauthored a Washington Post op-ed with Rosenberg, the very CDC official he squared off against when passing the amendment. Together, they argued for more gun-violence research.
Science does not determine policy, but it does inform policy. We need more science to better inform our national debate about the growing problem of gun violence and mass shootings.
It seems that those opposed to researching gun violence want to be stuck in a paralysis caused by insufficient information. They can oppose any gun legislation by arguing that there isn’t evidence proving the legislation will work. If that standard were used for all legislation we would have a very different style of government in our country.
I strongly advocate evidence-based government, making law is like practicing medicine in this regard. It is, at best, an applied science, which means there are value judgments involved, and often we need to make decisions in the absence of perfect information. So we use the best evidence available, within the principle of first do no harm, and evaluate the outcome.
Even with our current state of knowledge we can make rational decisions about gun regulations based on logic, plausibility and available evidence, then evaluate the outcome and make adjustments.
But more importantly, we don’t have to be stuck with our current state of knowledge. We can and should conduct research into the causes and potential solutions to gun violence. It is a health problem for our patients, and it is a public health problem for our society. The medical profession has a legitimate interest in preventing gun violence, and our publicly-funded health research institutions should be giving this topic the priority it deserves.
