More guns and less education is a prescription for poor health

Within the span of one week, my state of Kansas was headlined in two pieces in the New York Times, unusual for a small state. Unfortunately, neither was meant to be complimentary. “What’s the matter with Kansas Schools?” by David Sciarra and Wade Henderson appeared as an op-ed on January 8, 2014, and “Keeping Public Buildings Free of Guns Proves Too Costly for Kansas Towns”, by Steve Yaccino, was a news article (middle of the main section but top of the web page!) on January 12. Both are political and social issues; for example, the thrust of the “guns” article is that Kansas municipalities (like Wichita) that want to keep guns out of public buildings (like the library) are financially stymied by the cost of the security requirements the legislature has put in place in areas where carrying guns is not permitted. Like abortion (and neither of these pieces addresses Kansas’ virulent anti-abortion laws), guns are a very hot-button issue that inflames deep-seated passion in places like Kansas, and so is (sometimes) education. I will, however, focus my comments on the health impacts of these laws.

First, guns. Guns are, very simply, bad for people’s health. (Obviously, even when used as “intended”, for hunting, they are bad for some animals’ health, but this is not my focus.) Having guns around increases the risk of death or injury from them. Having guns intended for hunting stored locked and unloaded is the safest, but this doesn’t work for guns intended for self-defense since that renders them less available for that purpose. Carrying guns on your person, in your car, in public, on the street, and into businesses, public buildings, schools, and health care settings increases the risk. This is not what gun advocates, and concealed-carry advocates believe. Their idea is that there are bad guys out there carrying guns, either criminals who might want to rob you or crazy people who might want to shoot up your school or post office, and that carrying a gun allows one to protect oneself, and possibly others, by shooting down the perpetrator before more damage can be done. Thus, it protects your health, and that of others.

Nice idea, but completely unsupported by the facts.  Guns kill lots of people, injure many more, and virtually never save lives. This is the case even when used by police, and even more true when use of guns by police officers is excluded. It is true despite the widely-publicized, often repeated on the internet, and frequently invented stories about a virtuous homeowner shooting an armed robber. I have no doubt that such cases occur, but with such rarity as to be smaller than rounding error on the number of deaths and serious injuries inflicted by guns.  Suicides and homicides are among the leading causes of death in the US, most are caused by guns, and almost none of the homicides are “justifiable manslaughter” from a person protecting him/herself from an armed invader. The mere presence of easy-to-access guns in the environment increases dramatically the risk of successful suicide (see my blog, Suicide: What can we say?, December 12, 2013, with data from David Hemenway’s “Private Guns, Public Health”[1]). In addition, the number of “accidental” deaths (where someone other than the intended victim was shot, or someone was shot when the intent was “just” to threaten or show off, or by complete accident, sometimes when an unintended user – say a child – gets hold of a loaded gun) from guns is way ahead of any other method of harm (knives, bats, etc.)

When we go beyond having guns to carrying guns in public places, the data is less well collected. However, the trope of the heroic law-abiding, gun-carrying citizen drawing down on the evildoer in a public place, like say a movie theater or the waiting room of your clinic, is a terrifying thought. First of all, almost none of them are Bat Masterson or Wyatt Earp or Annie Oakley (except maybe in their own minds) and the idea that they will hit who they are aiming at is wishful thinking; the rest of the folks are caught in a gunfight. It is scary enough when this involves police officers, but if half the waiting room pulls out pieces, the results will be, um, chaotic. Harmful. Not to mention what happens when the police show and don’t know who to shoot at (maybe if you are a gun-toting good guy you can wear a white hat…).

So, having guns around, and the more easily they are available, is absolutely harmful to the health of the population, and generally you as an individual. If people, including legislators, and Kansas legislators in particular, want to encourage gun carrying for other reasons, they should at least be aware of and acknowledge the health risks. But what about education? The cuts in state education will, quite likely, harm the education of children (or if, as the article notes, the state Supreme Court forces the legislature to fund K-12, the education of young adults since the money will likely come from higher education), but what about health?

There is a remarkable relationship. More education leads to better health. Better educated people are healthier. The relationship is undoubtedly complex, because better educated people also have better jobs and higher incomes, which is also associated with health. This is addressed with great force in a recent policy brief “Education: It Matters More to Health than Ever Before”, by the Virginia Commonwealth University Center for Society and Health sponsored by the Robert Wood Johnson Foundation; for example, while lifespan overall in the US continues to increase, for white women with less than 12 years of education, it is currently decreasing! The RWJ site also includes an important interview with Steven Woolf, MD MPH, Director of the Center. “I don’t think most Americans know that children with less education are destined to live sicker and die sooner,” Dr. Woolf says. He discusses both the “downstream” benefits of education: “getting good jobs, jobs that have better benefits including health insurance coverage, and higher earnings that allow people to afford a healthier lifestyle and to live in healthier neighborhood,” and the “upstream” issues, “factors before children ever reach school age, which may be important root causes for the relationship between education and health. Imagine a child growing up in a stressful environment,” that increase the risk of unhealthy habits, poor coping skills and violent injuries.

In several previous blogs I have cited earlier work by Dr. Woolf, one of the nation’s most important researchers on society and health, notably in "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011. I included this graph, in which the small blue bars indicate the deaths averted by medical advances (liberally interpreted) and the purple bars represent the potential deaths that could be averted if all Americans had the death rates of the most educated. I also included a link to the incredible County Health Calculator (http://chc.humanneeds.vcu.edu) which allows you to look at any state or county, find out how the education or income level compares to others, and use an interactive slider to find out how mortality and other health indicators would change if the income or education level were higher or lower.

In the US, the quality of one’s education is very much tied to the neighborhood you live in, since much of school funding is from local tax districts and wealthier communities have, simply, better schools. (This last is completely obvious to Americans, but not necessarily to foreigners. A friend from Taiwan was looking at houses and was told by the realtor that a particular house was a good value because it was in a good school district. She called us an asked what that meant; “In Taiwan, all schools are the same; they are funded by the government. No one would choose where to live based on the school.”) This difference could be partially compensated for by state funding for education, which is why cuts in this area are particularly harmful, including to our people’s health. In fact the most effective investment that a society can make in the health of its people is in the education of its young.

An educated population is healthier. Wide availability and carrying of guns decreases a population’s health. Unfortunately, the public’s health seems to carry little weight in these political decisions.

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[1] Hemenway, David. Private Guns, Public Health. University of Michigan Press. Ann Arbor. 2007.

Public Health and Changing People's Minds

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In his Perspective “Why we don’t spend enough on public health” in the New England Journal of Medicine (May 6, 2010;362(10):1657-8), David Hemenway of the Harvard School of Public Health goes beyond the familiar complaint of the field that it is underfunded, particularly in contrast to medical care, despite the fact that it responsible for a much greater proportion of, well, the public’s health. He describes, as the title states, why.

“Medicine is primarily a private good — the patient receives the main benefit of any care provided. Payments usually come from the individual patient and, in the developed world, from private and governmental insurance. Public health, on the other hand, provides public goods — such as a good sewer system — and relies almost exclusively on government funding.”

The fact that public health provides a more general good would seem to be, well, good, but because it doesn’t as easily benefit a particular individual (me, or someone I know, or at least someone I can see a picture of) it is less engaging. People, Hemenway points out, are “wired” to value present need more than future benefit; cost today for potential benefit tomorrow is not easy to “buy” and is certainly rarely politically popular. In addition, the absence of disease (because it was prevented) is less obvious – and thus unfortunately less valued – than the cure of a disease that didn’t have to occur. We don’t wake up every morning and say “thank goodness I don’t have cholera because we have a clean water supply!”, but would be very grateful for a cure if we did contract cholera.

In addition, of course, and very importantly, Hemenway notes that while there are well-heeled advocates for spending money on medical care (e.g., pharmaceutical companies, hospitals, doctors), the money is generally working against public health measures which often threaten extra cost to business – regulation of air and water pollution, environmental restrictions, occupational health laws, smoking bans, alcohol restrictions. And especially gun-control, where opposition to minimal studies supported by the CDC on this major health problem were so opposed by congressmen influenced by the gun lobby that they effectively stopped research into this area. Or, more recently, where members of Congress such as Sen. Lindsey Graham (R-SC), tie themselves into verbal knots trying to show how hard they will be on suspected terrorists, and how many Constitutional rights they are willing to abridge – unless it is the Second Amendment, and mainly the NRA. When addressing the issue of restricting the ability of people on the “no-fly” list to buy guns Sen. Graham is uncompromising: “I think you’re going to far here.” (“Congress Up in Arms”, Gail Collins, May 6, 2010) .

Hemenway cites the example of “Baby Jessica” who fell down a well in Texas in 1987 whose story gripped the country: “As a nation, we will spend tens of millions of dollars to save one Baby Jessica but are often unwilling to spend an equivalent amount to prevent the deaths of many statistical babies…The scandal that people remember about Hurricane Katrina is not so much the lack of preventive measures (e.g., stronger levees) that would have averted the calamity but the inadequate rescue efforts.”

This is why TV commercials for “Save the Children” and like charities that show the faces of actual children, or even better the agencies that allow us to “adopt” specific developing-world children by sending money to them, the individual kids, are so much more effective than general appeals for contributions to help the oppressed around the world. It is also why, when the New York Times published “Faces of the Dead” on the 7th anniversary of the Iraq war, it was so much more powerful than simply saying “more than 4,000 have died”, or even listing their names. It is now an interactive site; click on any of the little boxes and the photo changes to that dead serviceman or woman, with their name, age, hometown and service branch. Please check this site out, but have a box of tissues beside you.

The more common tack taken by public health experts has been to try to provide more and more data, to policymakers and the public, about the importance of public health measures past, current, and (potentially) future, in the expectation, or at least hope, that this will convince them and result in a greater commitment (spelled, like all commitment, “M-O-N-E-Y”) to public health undertakings. Hemenway’s piece, demonstrating that anecdote, personal stories, and treatment of existing conditions that are actually hurting people, are more powerfully convincing than data, evidence, and effective prevention, must be very frustrating. Indeed, the issue (and I would say the problem) goes beyond public health to health and medical care in general; indeed it applies to most issues in the policy arena. Data, whether presented in “dry” tables, journal articles, Congressional testimony, or the media, does not seem to change peoples’ minds.

Hemenway says that “societal change is hard”, but so is individual change. The case for this conclusion is clearly presented by Christie Aschwanden in “Convincing the Public to Accept New Medical Guidelines”, in e-zine Miller-McCune, April 20, 2010. In this important piece, Aschwanden begins by looking at the unwillingness of long-distance runners to change their use of ibuprofen (“Vitamin I”) for preventing pain and inflammation even when studies demonstrated that its use made these problems worse and those results were presented to the athletes. The conflict between the phenomenon called “naïve realism”, which is “the idea that whatever I believe, I believe it simply because it’s true,” versus the actually more naïve belief that “truth wins”. She discusses the recent breast cancer screening recommendations, and the belief (in part the result of a successful program of “education” from cancer awareness organizations) that the more screening of the more people, the better.

“For years, women were taught the necessity of early detection for breast cancer based on the notion that breast cancer is a relentlessly progressive disease that will inevitably kill you if you don’t remove it in time. That story about breast cancer — call it the “relentless progression” mind model — is easy to grasp, makes intuitive sense and offers a measure of comfort: Every cancer is curable as long as you catch it in time.”

This is not a correct model, but it is hard to convince someone who had a mammogram, found cancer, had it treated, and is now alive, that mammography screening for everyone is not a good idea, much less that her cancer had a certain percent chance (much lower than prostate cancer, to be sure) of regressing on its own. I have addressed the breast cancer recommendations previously (Breast Cancer Screening and Evidence-based Medicine, November 25, 2009), so will rather focus on the studies that show, as she quotes social psychologist Robert J. MacCoun, “If a researcher produces a finding that confirms what I already believe, then of course it’s correct. Conversely, when we encounter a finding we don’t like, we have a need to explain it away.” I have previously noted that “data is only useful if it confirms my preconceived notions”; Aschwanden’s article cites study after study showing the same, on medical issues from breast cancer to low back pain. The President has called for more comparative effectiveness research (as have I, Comparative effectiveness research, March 27, 2010) but “How do you convince doctors and patients to dump established, well-loved interventions when evidence shows they don’t actually improve health?”

More generally, this is not just an issue with health beliefs. Aschwanden cites studies that demonstrated that people who believed Sadaam Hussein has weapons of mass destruction continued to believe it after being show evidence that it was not true. The opposite may occur, in fact; the presentation of facts that contradict your beliefs may serve to remind you of why you believe it and reinforce them. “It comes down,” Aschwanden writes, “to something the satirist Stephen Colbert calls ‘truthiness,’ a term he coined in a 2005 episode of his Comedy Central show, "The Colbert Report". ‘Truthiness is what you want the facts to be, as opposed to what the facts are,’ Colbert said. ‘It is the truth that is felt deep down, in the gut.’”

I admit to some my own truthiness. I want to believe, despite all this evidence, that people can be convinced by the evidence. That we will reconfigure the great imbalance of funding for individual medical care and public health because of the opportunity to improve people’s health and prevent disease; that we will choose prevention, screening, and treatment strategies based on evidence of effectiveness rather than myth or the financial benefit that accrues to the vendor of the service, and that we can unlearn that which is wrong as well as learn anew what is right. And that, even in the political arena, policy decisions may be guided by facts and reality rather than convictions. I know this is naïve, but I really want it to be true. Doesn’t that count for something?
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