Of Course Guns Are A Public Health Issue

The burden of bullets in health care

A rash of high-profile mass shootings and shooting incidents have highlighted the criminal aspect of gun violence in the US — how did people get access to these weapons, what weapons are people allowed to have, what background checks do they need to pass, etc. But this ignores the foundational problem: guns are hurting people.

During his nomination process, current Surgeon General Vivek Murthy nearly ran aground in the Senate due to comments he had made about gun control. I’ll let Jon Stewart explain:

If you missed it, the comment Dr. Murthy made that put him in hot water was “guns are a health care issue.” And for that, his nomination was delayed for months on end. Putting aside all political battles, he is right.

Amid the psychological horror of shooting cases, we often lose sight of the toll shootings take on public health. What happens if you try to look at guns as an endemic disease? What happens when you are diagnosed with a gun shot wound?

A WebMD page for gun shot wounds (GSW) would be horrific. Let’s design one for, say, the medical billing code W34.00XA: “accidental discharge from unspecific firearms or gun.” A list of common symptoms would range widely depending on the bullet entry and possible exit sites. The one certainty is severe bleeding and catastrophic tissue damage. Common causes of death include shock, exsanguination (bleed out), collapsed lung, or fatal injury to the heart, brain, or central nervous system.

The incidence rate of a non-fatal shooting is 23.7 per 100,000. To compare, Legionnaire’s disease, which is catching headlines for a recent outbreak, has an incidence of about 1 per 100,00. Gun shot wounds are also twice as common as all leukemias, and again almost twice as likely as all childhood cancers combined. At the time of writing, gun violence has killed 7,808 Americans so far in 2015.

Guns were intended to kill, and kill they do. Unintentional injury, suicide, and homicide are the leading causes of death for Americans age 15–34. Unintentional injury and suicide are included in the top ten causes of death in all age groups, while homicide makes the top twenty. While these are not all directly gun-related, firearm-related deaths top the list for cases of suicide and homicide. In 2013, there were 21,175 suicides-by-firearm, and between 11,000–14,000 homicides.

GSWs make up a much smaller proportion of reported fatal accidents, about 0.5% (or ~1,000 deaths in 2013). Yet focusing on this low number masks a more vexing problem: non-fatal gun injuries are slowly increasing. Not all flu patients are at risk of dying, yet the widespread disease is annually the subject of prevention and education efforts. Often, gun violence that is not fatal or the result of a mass shooting or shoot-out gets ignored.

The cost to human life typically holds sway over these discussions, but rarely has the actual dollar cost of gun violence in healthcare been addressed.

Firearm-related incidents make up about 6 in every 10,000 hospital visits. Given the violent nature of the “condition,” they result in a significant amount of emergency room visits — over 385,000 from 2006 to 2010. The emergency department is the most expensive part of the hospital — it’s why diverting low-income patients from the ER to primary care is a priority for increasing access to care— and the cost of treating a gunshot wound is staggering. One estimate places it at $154,000 per case in 1997, which comes out to be about $230,000 in 2015. That means we’re spending more than $88 billion. Other estimates put the cost as high as $126 billion on gunshot treatment annually. An additional $2.3 billion gets tacked on for care over the rest of the lifetime, $1 billion of which is directly tax payer funded.

That $126 billion figure means Americans spend more on the treatment of gunshot victims than the entire budget for the Department of Veterans Affairs. Using the lower $88 billion estimate, that’s more than all funding for NASA and the Departments of Transportation, Energy, and Homeland Security combined. We are pouring resources into an endemic problem that we’ve done nothing to prevent. When a case of Ebola virus was confirmed in Texas in 2014, American organizations and the US government pledged to spend over $2 billion on aid. In the past 72 hours, Milwaukee, Wisc. has had the same number of cases and deaths as Ebola caused in the United States during the 2014 outbreak.

This leads to the most damning problem facing concerned public health officials. The gold standard in prevention is the vaccine — an intervention that stops cases of disease before they happen, and prevents the disease from spreading to others. In this case, that vaccine is stricter gun control legislation — and we’ve seen it work elsewhere. The incidence of firearm-related homicides in the United States comes out to 3.3 per 100,000, ten times higher than each of the 34 OECD countries save Mexico, and stricter laws would also reduce the number of gun-related accidents.

Putting the call for stricter gun laws aside, the other issue is that the health care system finds itself blocked in other approaches as well. A large part of the money pledged for Ebola was earmarked for research — into vaccines, prevention, and treatment. In the United States, we can’t spend this money for research on the impacts of firearm use. The CDC is regularly blocked from tracking gunshot wound cases, and much of what we know is from reported crime statistics, not health researchers. Similarly, Florida recently passed a law preventing doctors from asking whether patients have a gun at home. Now Texas wants to follow suit.

Questions such as these aren’t an invasion of privacy. They’re an attempt by healthcare professionals to better know and treat their patients. Blocking efforts at research in this area is only depriving physicians from providing better outcomes to patients, and could inform public health officials on how to design interventions that would prevent gun violence in conjunction with the gun regulation that is already being practiced.

Ultimately, we are left with an endemic disease that kills thousands of Americans annually, with a price tag of approximately $100 billion each year. We have allowed the conversation surrounding guns to focus on philosophies of freedom instead of focusing on the health issue they represent. This is not the only societal behavior that has been changed through public health methods — the wide use of seat belts in cars and programs to stop smoking, drunk driving, and child abuse were all brought about through public health models. Our focus should be on stopping death and injuries from firearms.