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The Bullet as a Pathogen

This week, like millions of American parents, I choked back tears, harnessed emotions as best I could, and spoke to my second-grader about the events in Newtown, Connecticut. Despite the obvious emotions – disgust, fear, and bewilderment – I tried my best to present a measured explanation. Sometimes people do crazy, unconscionable things, but, all things considered, schools are safe, you are safe, and we will do everything in our power to keep you safe. Behind the sane façade, like so many others, I seethe. How can this happen in our society – repeatedly. For, this is no isolated event, this is an escalating pattern – Virginia Tech, Aurora, Clackamas and so many others and now – the fact that small children were massacred just makes it that much more heart-wrenching. Unfortunately, when it comes to gun violence, such tragic events tend to do little to address an actual solution – to the contrary most people just use events to bulwark what they already believe. Gun control activists will argue that better gun control would have prevented this tragedy, gun rights activists will bemoan the restrictions on concealed weapons on school grounds and various explanations – video games, movies, major holes in mental care services – will be proposed. But nothing will change, and it is only a matter of time until the next tragedy. But, what if we decided that gun violence should be considered differently – not as a political issue and not as matter of varied opinion, but as a matter of public health, as a matter where science might have an answer. Could that make a difference?

I, and many other health professionals, believe that bullets should be viewed as pathogens – like bacteria or tumors. If one views the problem through this lens, the question becomes simply how we can mitigate the effect of the bullet, and in this regard the aggregate medical opinion is quite clear – the best way to treat a victim of a gun shot wound is to prevent the gun shot from happening. It is a simple observation, but no one dies from a bullet that isn’t fired. The vast majority of gun deaths happen at the scene – these victims have catastrophic injuries that cannot be treated. Contrast this to some other disease processes, such as heart attacks or blood infections that can often be successfully treated, even in critical cases. Thus, from a public health standpoint, the bullet is a pathogen that, more than just about any other, needs to be prevented rather than treated after the fact. This may seem quite obvious, but our public policy is not at all attuned to this reality and for those who may doubt, consider a similar debate fifty years ago. In a time when the nation's roadways were unregulated death traps, many voiced concerns that improvements in highway safety were unnecessary infringements on freedom. But, over time, we have come to appreciate that speed limits, traffic safety signs, seatbelts, and airbags all save lives. Nowadays, road-related fatalities have drifted consistently down, and childhood fatalities from car crashes alone declined 41% from 2000-2009.

This is not a new concept. Public health researchers like Arthur Kellermann and Garen Wintemute have been promoting the public health paradigm shift for gun violence prevention for years. Now, maybe, just maybe, people and politicians are willing to accept this. We suffer an annual toll of more than 4 million gunshots, 400,000 gun-related crimes, and 11,000 firearm homicides. And consider the booming and mostly unregulated gun show industry, which makes it remarkably easy to purchase firearms, including excessively deadly ones (like the TAC-50 sniper rifle – which has a kill range of nearly two miles). Gun shows thrive despite evidence that regulating them (as California has done) decreases illegal sales and despite the knowledge that Mexican drug cartels are buying thousands of powerful weapons at U.S. gun shows.

So, what does a clinical approach to gun violence prevention mean? It means keeping guns out of the hands of violent criminals and the severely mentally ill. It should also mean recognizing that a preponderance of scientific evidence demonstrates that owning guns does not make us safer – that you are more likely to kill or be killed with your own gun than you are to peacefully prevent a crime. And it means making bullets less destructive, making enforcement of gun crimes tighter, cracking down on those who sell crime guns, regulating gun shows and stopping the flow of American guns to Mexican drug dealers. Most of all, it means changing the context of how we talk and think about gun violence.

My (rather conservative) British father-in-law visited around the time of the Clackamas mall shootings. Watching the news coverage, he said to me "I just don't understand America's obsession with guns." I considered telling him about the Wild West of yesteryear and John Wayne and Clint Eastwood and of the perceived sanctity of the Second Amendment. But, then I thought about it as a father and as a physician and replied simply, "I don't either."