Editorial

Rooting Out Gun Violence

Debra Malina, Ph.D., Stephen Morrissey, Ph.D., Edward W. Campion, M.D., Mary Beth Hamel, M.D., M.P.H., and Jeffrey M. Drazen, M.D.

N Engl J Med 2016; 374:175-176January 14, 2016DOI: 10.1056/NEJMe1515975

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References

Here we are again. Less than a year ago, an editorial in the Journal by Kassirer reexamined the massive public health problem of gun violence in the United States,1 and a Perspective article by Sacks, born of a personal tragedy, lamented the defunding of research on firearm-injury prevention.2 Kassirer called for electing “lawmakers at all levels of government with the courage to defy gun lobbyists,” so that essential regulatory changes can finally be enacted — as physicians, public health experts, and others have been recommending for decades. But in early December, the day after a young couple turned up at a holiday party in San Bernardino, California, with semiautomatic weapons and went on a shooting rampage, killing 14 people and injuring 21, Congress voted down a measure that would have prevented people on the terrorist watch list from getting guns and stalled on a measure to enhance background checks.3 An existing federal ban on military-style assault weapons, which ought to be an uncontroversial, if inadequate, first step, was allowed to lapse in 2004.

In 2013, the latest year for which the Centers for Disease Control and Prevention (CDC) has data, more than 33,000 people in the United States died from gunshot injuries and more than 84,000 survived with such injuries, many of them requiring ongoing care for both physical and mental health. After this year’s high-profile events in San Bernardino, Colorado Springs, Charleston, and Roseburg, Oregon, commentators once again marveled at the vast gap between U.S. rates of gun deaths and those in other developed countries, which either have never witnessed the epidemic of gun violence and the kind of mass shootings that are now routine here or have acted effectively to stop them.4 If any other public health menace were consistently killing and maiming so many Americans, without research, recommendations, and action by the CDC, the public would be outraged.

But in the United States, the National Rifle Association (NRA), the legislators it has funded, and a certain breed of gun owners have stood in the way even of research to determine what policies might help. The single or double gun deaths that go on around us every day rarely evoke any public response, and the predictable reflex response to the louder mass shootings, after exhortations to pray for the victims, takes two forms: calls for reviving research and calls for improving mental health care.

No doubt both of these avenues are important to pursue. Though the research pathway often feels like a delaying tactic doomed to encounter the same barriers that efforts to change laws face, House Democrats did on December 10 insert into an omnibus funding bill a provision lifting the ban on federal funding for gun-violence research. While the mental health care pathway, for its part, could have broader benefits, it would, at best, solve a tiny fraction of the problem — 3 to 5%, says Friedman, noting that “most people who are violent are not mentally ill, and most people who are mentally ill are not violent.”5 It also seems to make mental health workers or primary care physicians responsible for the impossible task of diagnosing and treating anyone who might conceivably start shooting people.

Most important, neither of these responses gets at the root of the problem. Something in the psychological or sociological makeup of the United States has left us at this long-standing impasse. Gun-control advocates blame the NRA, but perhaps the NRA is less like a foreign pathogen that has invaded our body politic, to which we could mount an immune response, than like a cancer, growing from our own mutated cells. And that dangerous mutation seems to be a sad distortion of the American principle of individualism that prioritizes one’s right to live the way one wants, without any government interference, over other people’s right to live at all — a distortion that has found one of its key expressions in firearm-related freedoms. But gun violence is an assault on the health of the public. An equally fundamental American principle holds that ensuring the public health sometimes requires curbing the rights of individuals in order to benefit and protect the community as a whole.

Previous commentators including Hemenway and Miller have listed among the steps toward reducing gun violence “changing social norms.”6 Given that it requires “deep cultural changes,”1 however, that is far easier said than done — it is, as Wintemute has argued, “the work of generations.”7 But it is work that we need to begin. If we never address the underlying beliefs that sustain this guns-everywhere extremism, we will not be able to diminish its power. Too many Americans will continue to get their hands on assault weapons, too many will kill or maim other Americans, and we will continue to bicker about whether the first step is more research or better mental health care — while we continue to do nothing to cure the disease.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article was published on December 16, 2015, at NEJM.org.