I have been somewhat reluctant to write about the issues
surrounding the mass shootings that have become epidemic in our country. Since
the Newtown elementary school massacre it appears as if everyone else has done
so, and I didn’t know what, if anything, I could add that would be of value. I
still don’t, but I would like to try to emphasize the public health and medical
issues here. Everyone talks about getting beyond rhetoric, but mostly we hear
rhetoric and have yet to see results.
In his column in the New
York Times on December 28, 2012, “Guns
and Mental Illness”, Joe Nocera addresses those two aspects of the
controversy, which I agree are the key ones. However, while I generally think
his points are valid, I disagree with his characterization that gun control is
a “liberal” issue while mental health has been the focus of conservatives. For
good, or bad, and too often bad, both issues have been neglected by too many
for too long. When it comes to death, dramatically in the case of mass killings
such as Newtown or Aurora or Columbine, much more commonly in “simple”
individual killings, and most commonly in the case of suicide, they are tied
together. Nocera starts with mental health, so I’ll start with guns.
I have written about guns several times before (“Mexican
Murders and US Guns”, March 24, 2009,
“The
Arizona shootings: When will we ever learn?“, January 9, 2011, “Why
we don’t spend enough on public health”, September 22, 2011, and even
discussed a New England Journal of
Medicine article (Why
we don’t spend enough on public health”)[1]
by Dr. David Hemenway of the Harvard School of Public Health and Director of
their Injury Control Research Center and Youth Violence Prevention Center (“Public
Health and Changing People's Minds, May 15, 2010). Guns are efficient and
effective killing machines. This is, after all, the reason that hunters and
warriors like them. They can be made more efficient, by being automatic or
semi-automatic, and by having magazines that hold many bullets. These are
generally considered positives on the war side (and by gangsters), but are
often seen as “un-sporting”, so that most states have laws governing their use
in hunting. The statistics on gun violence in the US are staggering, and seen
from a public health perspective represent a severe and continuing epidemic.
Likely the best book on this topic is “Private Guns, Public Health”[2],
by Dr. Hemenway. He presents extensive statistics on injury and death resulting
from guns, and emphasizes a addressing this problem through efforts to both
increase the safety of guns themselves (as we have for cars) and limiting their
availability (as we have for cigarettes). This is a harm-reduction approach.
Much of the data cited by Hemenway is sobering, and some is so
downright shocking that one might think it difficult to ignore. There are over
30,000 suicides in the US per year, and a high proportion are from guns,
because guns are much more effective, and are less likely to allow a second
chance; the “success” rate for suicide by gun exceeds 95% while for intentional
overdoses it is less than 5%. One of the populations most at risk for suicide is
young men; Hemenway notes that the successful suicide rate in this group is
several times higher in “low gun control” states (mostly Southern and Mountain)
than in “high gun control” states (mostly Northeast and Hawaii). This is not
because of less suicidal intent in, say, Massachusetts than Montana, but the
easy availability of guns.[3]
But we know about the effectiveness of guns. You can kill
someone with a baseball bat, or a knife, or a lead pipe or wrench or
candlestick in the Library, but not as efficiently, reliably, effectively, and
potentially randomly as you can with a gun. The recent episode of a
knife-wielder in China is one example. Adam Lanza wouldn’t have been able to
kill many with a candlestick. Innocent children are rarely victims in drive-by
knifings. The NRA used to say “guns don’t kill people, people kill people”.
Yes, but they do it much better with guns. Now they say that the solution to
“bad guys with guns” is “good guys with guns”. This is so ridiculous (can you
imagine a bunch of “good guys” blazing away at whoever they thought might be the shooter in the dark
in the Aurora, CO, theater?) that NRA bumper stickers are now being amended by
new ones saying “Not MY NRA!” in response.
What about mental health? Nocera does an excellent job of
summarizing the problem confronting the chronically mentally ill; with a
progressive philosophy of “de-institutionalization” mental hospitals were
closed with the promise of comprehensive, community-based mental health
services being available in the community. But, of course, funding was not
forthcoming for those services, nor does it appear that it will ever be
adequate. Nocera is correct in saying conservatives have pointed to mental
illness (rather than guns) as the cause of such violence, but in addition to
not supporting any gun regulation, these same “conservatives” have led the
charge in de-funding and under-funding mental health services. The constituency
supporting such services, especially for those who cannot afford private care,
is not big or effective enough. Apparently these politicians are in favor of
supporting (retroactively) mental health care for those who commit mass murder,
but not prospectively for the millions in need. One word that is commonly used
for such an approach is “hypocrisy”, but this does not shame politicians.
I have written about the “sensitivity” and “specificity” of
tests, particularly with regard to screening.
However, the same concept can be used for assessing risk of any
condition, such as mental illness and the probability of committing gun
violence on a large scale. If “committing mass murder” (as opposed to
individual homicide or suicide) is considered the disease, then assessing for mental illness would be pretty sensitive
– that is most mass murderers are mentally ill and there are relatively few
“false negatives” – people who are mass murderers but not mentally ill. But it
is pathetically not specific, for the
overwhelming number of mentally ill persons will never be mass murders. They
would be “false positives”. But this in no way means that they should not receiving comprehensive and effective mental health services.
So, which is the greater problem? Which should be addressed
first? The answer is both, and, more to the point, either would be an improvement. On guns, there need to be bans on
assault and automatic weapons and on high-capacity clips and “cop-killer”
bullets, and background checks on gun purchasers and closure of the “gun show
loophole”. On mental health, there need to be ubiquitous and well-funded mental
health treatment programs in all of our communities, with outreach workers and
close collaboration with primary care medical providers. Both strategies are
critical, both are quite (although, obviously, not completely) effective in
other countries.
But I would be happy if we would do one of them. I mostly,
however, hear a lot of talk and am fearful that we will, ultimately not do
either.
[1]
Hemenway D, “Why we don’t spend enough on public health”, NEJM 6May2010;362(10);1657-8.
[2]
Hemenway D. “Private Guns, Public Health”. University of Michigan Press. Ann
Arbor. 2004.
[3] Full disclosure: Ten years ago, my
24-year old son committed suicide with a gun. As far as I know, he’d never used
one before. He left his home in a “high gun control” state and went to a “low
gun control state” where he knew no one, acquired the gun, and completed his
suicide. A testimony to the impossibility of preventing suicide? A condemnation
of the ease with which he obtained the gun? Make of this what you will.
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