Sunday, October 22, 2017

Guns and the Public's Health: what can we do?

 "A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed."

Recognize those words? The Second Amendment to the Constitution of the United States, what all the fuss is about. In addition to the confusing use of commas, apparently more generously applied in the 18th century, we have two key phrases. The final phrase, “shall not be infringed”, is read by the NRA and other “gun rights” zealots (and it is important to remember that only a minority of NRA members, and a smaller minority of gun owners, support this position) to mean essentially “no legislation regulating guns in any way”. That includes assault rifles, semi-automatic and maybe even automatic rifles, armor-piercing (“cop killer”) bullets, and any other weapon or gun modification that creative minds can come up with. Of course, it has been noted that none of these types of weapons were available at the time of the Constitution, when firearms were muzzle-loaded muskets, quite different from current weapons (see graphic).

The NRA take the position that there is qualitatively no difference, as noted by its President, Wayne LaPierre, after the December 2012 massacre at Sandy Hook Elementary School: "Absolutes do exist. We are as ‘absolutist’ as the Founding Fathers and framers of the Constitution. And we’re proud of it!" Others (including me, in case you were wondering) would disagree, and say that clearly at some point the quantitative difference becomes qualitative. This is the only amendment they are absolutist about; the First Amendment says “Congress shall make no law… abridging the freedom of speech…”, but it has long been settled that it is not OK to yell “Fire!” in a crowded theater.

The other obviously important phrase is “A well regulated Militia”. Again, obviously, this has been the source of much discussion, with the NRA taking the position that “Militia” just means “everyone” (kind of a stretch), and (as far as I can tell) “well regulated” means, um, not regulated at all. Is this cherry picking the words one wants? Maybe, but I can’t imagine how it is possible to ignore completely the words “well regulated”. But does it matter? Yes, when we live in a country where
The 36,252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36,161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.
-Bauchner et al., Death by Gun Violence—A Public Health Crisis, JAMA, October 9, 2017[1]

Those are staggering numbers, and certainly justify the assertion that it is a “public health crisis”.

The authors also note that “60.7% of the gun deaths in 2015 in the United States were suicides, a fact often ignored. That is a majority. A large majority. If it were an election, 60.7% would be considered a landslide. But with guns it is a mudslide of death. I have written before about suicide (e.g, Suicide: What can we say? December 13, 2013, Suicide in doctors and others: remembering and preventing it if we can September 14, 2014, Prevention and the “Trap of Meaning” July 29, 2009) and its impact on myself and my family, with my son’s successful suicide-by-gun at the age of 24. My son, to my knowledge, had never used a gun before his final act. He lived in a state and city with strict gun control laws (some of which, sadly, have been eliminated by the courts). He was nonetheless able to go to another state, buy a carbine (terrific choice! No permit needed, even in those days, like a handgun would require, but short enough to reach the trigger with the barrel in his mouth!), and use it. It would be easier now, in that state and many others.

My son was apparently very committed to this act, and was successful despite some obstacles. But for many, many people it is the availability of guns that make a spur-of-the-moment decision lethal. I have noted before that nearly 95% of suicide attempts by gun are lethal while less than 5% by drug overdose are. My clinical experience is that many suicide survivors do not repeat their attempts (though many do). The successful suicide rate for young adult males in low gun control states is several times higher than in high gun control states. And on and on.

But the epidemic of suicide and murder and mass murders resulting from the easy availability of guns has not changed the legal landscape. After the Las Vegas massacre, there was a small ray of hope that maybe one of the most egregious products the white terrorist Stephen Paddock used, the “bump stocks” that effectively convert semi-automatic to automatic rifles, might be limited; even the NRA voiced some possible support. But never underestimate the cowardice and lack of moral fiber of the Congress; Speaker of the House Paul Ryan has suggested that this be done by regulation rather than legislation. This is absolutely because it will not require any congressperson to actually vote for it and thus be targeted by the zealots in the next election. Hopefully, not literally targeted by guns, but do not forget Gabby Giffords and Steve Scalise!

Dr. Bauchner, who is the editor-in-chief of JAMA, also joined the editors of several of the other most prestigious US medical journals, New England Journal of Medicine, Annals of Internal Medicine, and PLOS Medicine in an editorial that appeared in all their journals (this link is the the NEJM), ‘Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’.[2] Again, this emphasizes the fact that guns are a public health epidemic in the US, and that there is little likelihood of anything being done at the federal level to stem its carnage. It recognizes that there is a variable response at the state level, with some states going as far as trying to legally prohibit physicians from asking about guns in the home (Florida; since struck down by the courts) while others have had stronger regulations. Many legislatures have also acted to prevent the cities in their states from acting independently to regulate guns in any way. One of the most insane was the state of Arizona suing to prevent the city of Tucson from destroying guns seized from criminals. The legislature mandated that they be sold – thus keeping them on the streets – and the Arizona Supreme Court upheld this, saying state law trumped local ordinances!

Given this situation, the joint editorial suggests that there are many things that physicians can and should do, including (quoted):
·        Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don’t wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury.
·        Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with local, state, and federal governments. Don’t let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press.
·        Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents. [this is what the Florida law would have made illegal]
·        Don’t be silent.

The first (JAMA) editorial says:
Guns kill people….the key to reducing firearm deaths in the United States is to understand and reduce exposure to the cause, just like in any epidemic, and in this case that is guns.

The fact is that while physicians have influence and moral authority, so do other health professionals, and, in fact, so do all of us. So the advice must pertain to all of us.

Don’t be silent.

[1] Bauchner H, Rivara FP, Bonow RO, Death by gun violence—a public health crisis, JAMA online Oct 9, 2017, doi:10.100/jama.2017.16446
[2] Taichman DB, Bauchner H, Drazen JM, Laine C, Peipert L, Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’, October 9, 2017DOI: 10.1056/NEJMe1713355

Friday, October 13, 2017

Fake news, fake facts, and fake science: making stuff up to justify hurting people and the planet

The flood of “fake news” threatens serious damage to our society as surely as floods have recently destroyed much of the Caribbean and coastal US or fires have burned up much of Northern California. While it is President Trump (whom I call the #Trumpenik, from the Yiddish “trombenik”, a lazy person or ne'er-do-well; a boastful loudmouth) who uses the term most often, in fact it is he and his allies who create most of the falsehoods. A central and terrifying one is the denial by the President and his EPA of global warming, certainly linked to the increase in horrific storms and fires, and the counter-scientific efforts of his administration to make it worse by increasing the burning of fossil fuels and refusing efforts to contain climate change despite the fact that it is “Trump country” that is supplying much of our nation’s alternative energy

Key to this fake news is the use of “fake facts” to support reactionary political agendas. While these agendas are mostly about making more money for the richest people and corporations rather than the middle and working-class Americans who support them, they also exploit a bizarre antipathy toward science among a good hunk of our population. (One explanation is that science sometimes reveals facts that are incompatible with pre-existing beliefs, so we reject them. However, the Catholic Church finally got over its opposition to Galileo, so maybe there is, eventually, hope.) Indeed, these people don't oppose all scientific facts, but rather those that make them uncomfortable despite being true. This is suggested by the efforts to manufacture false “scientific” facts to buttress social agendas. A prominent example is the use of “fetal pain syndrome” to justify efforts to limit access to abortion, particularly in the second trimester. The flaw here, of course, is that the evidence for fetal pain is slim to none, certainly before the third trimester, as shown is several reviews of the literature, and discussed at length in this article in Popular Science. notes that “The American College of Obstetricians and Gynecologists (ACOG) said it considers the case to be closed as to whether a fetus can feel pain at that stage [20 weeks] in development.” Of course, while the number of people who would change their positions on the availability of second-trimester abortion if they believed that the fetus experienced pain during the procedure would be small to minimal, it provides a convenient, if false, cover for efforts to restrict access, including a House bill that passed just this month in Congress.

This use of fake facts and junk science has recently been expanded beyond restricting abortion to efforts to limit access to contraception for women. Let’s get this completely straight: access to contraception has been a terrific thing. It has given women – and men – much greater control of their reproduction, dramatically reduced the incidence of unintentional pregnancy (although this still remains far too high), and, duh!, even reduced the incidence of abortion. While the decision to use contraception should and does remain up to the individuals involved, it needs to be easily available to them. Thus access is critical. For many – including but not limited to teens – access is, instead, very limited, and there are ongoing efforts in Congress and in many states to further restrict it. Particularly onerous and vile is the effort of the Trump administration to roll back the ACA’s mandate for insurers to cover birth control, pandering to the religious right.

A terrific piece by Aaron Carroll on October 10, 2017 in the NY Times, “Doubtful science behind arguments to restrict birth control access”, details and refutes the bogus claims made by those who want, bizarrely, to do so. These include the idea that access to contraception has not reduced unintended pregnancy (it absolutely and most assuredly has, and greater availability would further reduce it). The Trump (and at the time, Tom Price-led) Department of Health and Human Services used cherry-picked and archaic data to support its tortured argument. Carroll notes that “In 2011, the unintended pregnancy rate hit a 30-year low. And the teenage pregnancy rate and teenage birthrate right now are at record lows in the United States. This is largely explained by the use of reliable and highly effective contraception.”

HHS also argues that there are health risks, especially from hormonal contraceptives. There are, of course, but there are health risks and side effects from any drug treatment, and the risk of harm from the treatment has to be weighed against the probability of benefit. Ironically, in the care of hormonal contraception, the most significant side effects (both symptoms and even blood clots) are similar to (if generally less severe than) those from the condition contraception is designed to prevent – pregnancy. That is, not using contraception because of concern about these side effects and then getting pregnant increases the risk of these adverse events!

The bugbear for religious conservatives in this debate is their fear that contraceptive availability will increase people – especially teens -- having sex, but for the rest of us the concern is how this would impact the unintended pregnancy rate. Carroll cites a “2016 study in The New England Journal of Medicine showed that the unintended pregnancy rate among women who earn less than the federal poverty line was two to three times the national average in 2011. An earlier study showed that in the years before, that rate was up to five times higher.” From a cost point of view, the study’s author, Jeffrey Peipert, notes that “Every dollar of public funding invested in family planning saves taxpayers at least $3.74 in pregnancy-related costs.” For women (and their partners), especially those who are low-income or teens, the direct cost for contraception is sometimes prohibitive, especially for the most effect type of contraception, long-acting reversible contraception (LARC), IUDs and hormonal implants, that have a high one-time up-front cost. It is the programs to make these more affordable and available are exactly the ones being targeted for major cuts. And, in the “adding insult to injury” department, the justification for cutting some programs is sometimes the existence of other programs, which are also being targeted for cuts!

The use of junk science, sadly but unsurprisingly, is not limited to contraception, abortion and even climate change. In a Viewpoint piece published in JAMA, October 10, 2017, “Flawed theories to explain child physical abuse”, John Leventhal documents a new trend in legal cases of child abuse. Defense attorneys bring in “medical experts” who testify that something else could have caused the child’s injuries. These include real diseases that could cause the findings but are both uncommon and can be ruled out with proper workup, real diseases that are very uncommon and unlikely to cause the findings, and essentially made-up conditions to explain the findings. Since child abuse is generally not a controversial area (nobody claims to be in favor of it!) the reasons for this seem to be mainly personal gain – such “experts” make big money for this testimony. There are not that many real experts in child trauma willing to offer absurd pseud-explanations for the injury, so there will be fewer of you willing to testify in defense of the perpetrators, so you again stand to make a lot more money.

In any case, the use of fake or fraudulent science and fake facts to support political agendas is one of the many bad things growing in the fertile “don’t try to tell me the facts” environment in Trumpian politics. The administration is now allied with “traditional” Republicans to facilitate rape of the planet in pursuit of gains for the wealthiest, and with “populists” in pursuit of social repression. There is some irony in that these advocates for “freedom” (e.g., from gun control) are so intent on denying it to others (e.g., gays, women, poor people, children), but apparently this is a long-standing US tradition (see: slavery), which inspired Abraham Lincoln’s famous quote “Those who deny freedom to others deserve it not for themselves,” There is also irony in the pursuit of the cloak of (fake) scientific facts to facilitate an anti-scientific agenda.

But the irony is not nearly sufficient satisfaction to mitigate the terror.  

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