Frantic parents raced to Sandy Hook Elementary School in Newtown, Conn., their hearts and time itself seemingly standing still as they searched for their own among the groups of scared little kids herded to the nearby firehouse. The lucky ones felt a flood of relief at reunions. But there remained a group of adults, gathered in a separate room of the fire station, standing in hushed silence. They awaited news of their unaccounted-for children or loved ones. The New York Times reported on Dec. 15 that when those 26 sets of parents and relatives heard the worst possible news, "the wails that followed could be heard from outside."
Richard Riggs, my colleague who chairs the Department of Physical Medicine and Rehabilitation, knows it doesn't take his level of expertise to grasp that this scenario -- children and loved ones who will never again come home -- tragically will be repeated, unless there's major change in America. "There are two big things that gunshot wounds can do," he said. "Death, of course, is the first."
The second big thing is the type of injury that is his area of expertise, profound harm requiring months or years of rehabilitation. Riggs has seen plenty of gunshot injuries. Many of the victims will never be the same. "If [a bullet] hits part of the central nervous system, the spinal cord or the brain, life changes -- forever," he said.
Bullets worse than disease
A bullet through the brain differs from any disease disruption of brain function. Gunshot wounds to the brain often get compared with strokes. They are worse. "In a stroke, you have a blood supply that's interrupted. The rest of the brain is intact. There is no injury or exit point that interferes with other structures," Riggs said. We're used to hearing that different parts of the brain are responsible for various functions: reason, emotions, walking, left or right arm movement, language. But research tells us there are key supporting structures and connecting paths that help those brain locations send and receive information. "You need all those connections to work. With a stroke, you have all the other supporting structures there to support recovery," Riggs said. "With a bullet in the brain, often the recovery is worse because the neural path has been interrupted both to and fro." Similarly, when a bullet hits the spinal cord, the injury is almost always complete, compared with other traumatic injuries to the spine that might be partial or incomplete.
Television and movies deceive us into thinking the consequences of gun violence may be fatal but instantaneous. Clean. Bang, you're dead. Or bang, you're back in a few minutes on camera, where simply, you've just got a bandage, sling, or limp, doing what you've always done. Popular films don't show wheelchairs or colostomy bags. They don't show the grownup frustration of relearning, like a baby, to speak or walk. They don't show memories vaporized in a devastated brain. The movies aren't filled, as they were in my youth, with cowboys and Indians, with six-shooters, rifles and bows and arrows. Drive around the streets of Los Angeles, headquarters of movie-staged mayhem, and you'll see a billboard of a former governor wielding a bazooka. Or two-handed gun mastery amid fiery chaos in a movie suggesting that some people are "expendable." This is what our kids see, along with video games with the goal of virtual killing and mayhem. The message is that guns equal excitement, masculinity and control. We need to dial down society's testosterone level.
Basic numbers don't explain
So how do we begin to tackle the enormity of this national problem before more innocents die? It's an undertaking of monumental proportions, given that there are some 270 million civilian-owned guns in the United States, or 88.8 guns per 100 people, giving us the distinction of being ranked number one out of 179 countries with data. Of the more than 16,000 murders in 2010, about 11,000 were caused by guns. About an equal number of people died from gun-related suicides and accidents.
The national political reaction to the Sandy Hook killings has been sharp and divisive. President Obama, in the White House on Wednesday, called on Congress to enact a number of control measures to: renew a ban on assault weapons, require more detailed and extensive background checks of all weapons' buyers, restrict high-capacity ammunition clips and expand trafficking laws to crack down on the spread of arms nationally. He said he would use his executive authority to step up enforcement of existing gun laws and to improve information sharing among federal, state and local agencies to try better to keep guns out of the hands of those who should not have them, including criminals and the mentally unstable.
The president and his advisers, however, made clear that any legislative action likely would be subject to hostile reaction from gun advocates. While New York lawmakers acted with alacrity on a gun control package and new measures have been proposed in California and Massachusetts, the fate of new national laws remains uncertain.
Gun lobbyists argue, for example, that more guns equal more safety and security. Studies show, however, that gun ownership increases the risk of homicide or accidental injury in the home, probably the most cited being a 1993 study in the New England Journal of Medicine.Researchers found that having a gun in the home more than doubled the risk of murder, and virtually the entire increased risk of homicide came from within the household — a family member or intimate acquaintance.
Studies such as this one have become rare. In the mid-1990s, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control was stripped of $2.6 million in research funding. Language from Congress at the time included: "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." So research became politicized, and that means we have data on the number of deaths and injuries caused by guns but very little scientific work on the underlying causes of that violence. It seems that some lawmakers would rather take an ostrich stance than have to deal with carefully derived data that may challenge their biases.
While we clearly need more basic information -- and the president took a great step on Wednesday by lifting the ban on CDC research, calling for more funding for it and urging steps to allow caregivers to play an appropriate role in alerting authorities to potentially dangerous individuals, as well as protecting healthcare facilities from gun violence -- we already know a lot about tapping public health tools to not only improve health but also to profoundly shift cultural attitudes and behaviors. When we think of public health, we think of a clean water supply, mass immunizations and basic cleanliness like hand washing. These measures helped solve the scourges of cholera and polio and go a long way in reducing contagious diseases and infections. In retrospect, they seem sensible and relatively simple, yet they have formed the basis for public health improvements that reach beyond medical solutions. There are important, and successful, precedents for the view that public health measures could address gun violence.
Let's also make clear why this approach, perhaps more painfully slow than some other means, might make greater headway on a seemingly intractable issue: Those who embrace guns and wrap themselves in the Second Amendment, notably the National Rifle Association, are absolutist and, thus far, have been utterly unyielding. As commentators -- and comedians -- have pointed out, the bombastic opposition somehow roots itself in the notion that any laws about guns lead inevitably to extreme, confiscatory actions by an overreaching Big Brother government.
Well, we need only turn to the public health efforts on cars and tobacco to see that no one has snatched away Americans' vehicle ownership -- there are more than 240 million on our roads now. And as much as I know that they're still one of the great detriments to health, more than 300 billion cigarettes are sold in this country. We didn't take away anyone's "rights" with these products, but we've made the nation and the world smarter and healthier about them. And while I fully support the president's proposals, we also need to pursue a public health approach to guns and their associated violence.
What we learned with tobacco, cars
With tobacco, we took steps inspired by public health campaigns to help slow rates of lung cancer, heart disease and other tobacco-related health woes through education that changed attitudes. It took decades. Some of us can remember Lauren Bacall and Humphrey Bogart falling in love, on screen and off, as they took sexy, glamorous and long drags on cigarettes. We can recall when almost every office desk had an ashtray and patrons smoked in theaters, restaurants, airplanes, elevators and bars. It was largely public health interventions that over time painted a decidedly different picture of smoking, a portrait with ugly wrinkles, the damage to the young especially of second-hand smoke, and, of course, the ravages of tobacco-related disease and deaths. Advocates campaigned to oust cigarette commercials from television shows and movies. Smoking, once allowed throughout restaurants, was banished to special sections, and then finally it was barred completely in public eating spaces. It seemed unimaginable that a once ubiquitous habit could be vanquished. But consider that for health reasons, you can't smoke any more in Irish pubs — that's how the awareness has taken hold. The anti-smoking public health campaign began in America in earnest in 1965 with the first Surgeon General's report on smoking; 42.4 percent of adults smoked then while only 18.9 percent of adults do so now.
Taking their cues from the tobacco campaign, driving safety advocates also tapped into a public health education model. Their campaigns, with decades of education, resulted in safer vehicles, seat belts, air bags, child safety seats, divided highways and drunk-driving laws. Motor vehicle deaths have been dropping from their high of more than 50,000 a year in the late 1970s to the most recent fatality count of slightly more than 30,000 in 2010. And, of course, we Californians -- especially the millions of us in the Los Angeles basin -- can only shake our heads in wonder at the suffocating smog in Beijing and praise the long-running, difficult efforts to clean up auto and other airborne emissions in the Golden State.
We've got a ways to go still with smoking and vehicular safety. But let's put the public health cross-hairs now, please, on guns and their accompanying violence.
Changing gun attitudes, behaviors
After the Newtown shootings, a group of public health researchers, in the Journal of the American Medical Association, argued for campaigns against guns and violence, comparing successful battles with cigarettes and road safety. We tax tobacco to discourage young smokers and to use the money to support education and smoking cessation programs, they said. Why not tax guns and ammunition and use the money for gun safety and violence reduction programs? We changed attitudes toward cigarettes by getting them off the big and small screens and by getting them out of the workplace and restaurants. Why not work with Hollywood to get gun violence off the screen and supplement a new message with public campaigns on the real-life consequences of gun violence? Ditto with the video games makers, as the president urged. Physicians routinely ask patients if they smoke. Why not have medical personnel ask if there are guns in the home, and follow up the question with materials on safe use and storage of guns?
In Florida, conservative Gov. Rick Scott and his GOP legislative allies sought to bar MDs from asking just such questions and a court battle ensued -- a dispute that local wags dubbed "docs vs. Glocks." The physicians won, with a federal judge striking down the law that sought to muzzle this possible way to better public health. As Carl Hiaasen, a Florida columnist and noted novelist, observed, MDs ask lots of tough, intrusive questions aiming to better their patients' health. And those opposed to their asking about guns had to face up to factual issues — such as why one out of every 25 children delivered to pediatric trauma centers has a gunshot wound (according to the American Academy of Pediatrics).
We've done crash safety research and used results to bring higher standards of safety to the auto industry. Why not use research standards to come to a national agreement on such dangers as huge ammunition clip size and rapid-fire assault weapons? We've introduced passive restraints like seat belts, air bags and child safety seats. Why not implement passive restraints to guns, like automatic locking devices or security devices that won't allow a child or a thief to operate the weapon?
We have created a society with fewer smokers and vastly more smoke-free environments. We have created automobiles and roadways where people are much safer when they drive and our air is cleaner and healthier. Isn't it time to use our public health resources to help create a less aggressive society for ourselves, and especially for our children? Now is the time for Congress to do its part and pass the legislation that President Obama has asked for.