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Yes, gun violence is a public health problem

There are times when I have to rub my temples and the bridge of my nose hard to try and prevent a headache from something I see or read. I have to remind myself that there are people out there with some very “interesting” opinions about things that are obvious to me. There are anti-vaccine people who, despite all the overwhelming evidence in the medical and scientific literature — and the fact that there is no polio anywhere near them — continue to deny that vaccines work. And there are people who see the melting of the polar ice caps and the strange weather phenomena and still say that everything is okay and that we can continue to pollute the planet as we see fit.

That’s fine. People are entitled to their opinions. The problem with such opinions is that they matter when they are coming from someone with some sort of authority on the matter. This is the case in a blog post by Dr. Paul Hsieh, a medical doctor, titled “No, Gun Violence Is Not a ‘Public Health’ Issue.” I knew I was going to read something that would make me rub my temples when I saw “Public Health” in quotes within the title. (People often do that to make whatever is quoted seem like an abstract idea, like someone who says, “They want me to take their ‘vaccine’ to avoid getting polio.”)

Dr. Hsieh, it should be noted, is one of the founding members of the “Freedom and Individual Rights in Medicine” group. Now, that’s a website that made me rub the bridge of my nose, close my eyes, and shake my head. The site has such entries as “Health Care is Not a Right” and “How To Protect Yourself Against Obamacare“. Because, it seems, you have no right to get treated for something that might take your life. It must be a privilege. And, apparently, Obamacare is a construct that will come at night and take your children, or something.

But let’s get back to Dr. Hsieh’s blog post on He starts us off with a quiz:

“Which of these things is not like the other?

  1. Measles
  2. Influenza
  3. Tuberculosis
  4. Murder

If you picked #4, “murder,” you’re right. The first three are medical diseases. In contrast “murder” is not a medical problem, although it is a tragic cause of death. But in recent years, anti-gun organizations (and some physicians) are seeking to blur this distinction by declaring “gun violence” to be a “public health” problem.”

I have to thank him for making the answer so obvious. Murder is not an infectious disease caused by a virus or a bacteria. I was going to answer “murder” as well, but only because we don’t have a vaccine against it. Anyway, you probably can see the set-up. I’ve seen this technique in denialist blog posts, where the writer starts off by pretending that something is too obvious for us to oppose it. I mean, if you say that murder is just like the other infectious diseases there, you’d be wrong, so the rest of the dissertation by Dr. Hsieh must be correct… Right?

His first argument is that he doesn’t understand the term “epidemic.” Wait, no, that’s not his argument. His argument is that gun violence is not epidemic, because epidemics are caused by “infectious agents transmitted between people, often without their knowledge” and, thus:

“In contrast, “gun violence” is typically caused by malicious or negligent misuse of a firearm outside of legitimate settings such as hunting, shooting sports, or lawful self-defense. Unless the shooter is a psychiatric patient, such shootings fall under the jurisdiction of prosecutors, not doctors.”

This reminded me a lot of the times that I’ve had to explain the term “epidemic” to many people who should know better, some of them physicians like Dr. Hsieh. An epidemic is the occurrence of anything in more than what is expected for a location and during a period of time. It’s not only about infectious disease. There currently is an epidemic of obesity and diabetes. There have been epidemics of suicides. There will be epidemics of non-infectious events in the future.

When we look at gun violence, we can see that there are these “outbreaks” (a term used interchangeably with “epidemic”) of gun violence when we have schools being shot up. However, overall gun violence has been on the decline since 1993. So he is correct that we are not experiencing higher-than-expected levels of individual gun violence, but he is mistaken if he thinks that the term “epidemic” doesn’t apply with regards to mass shootings. Now, more than ever, we are seeing more and more mass shootings than “average” or expected.

For his second point, Dr. Hsieh states that “if “public health” includes “gun violence”, then intellectual fairness demands that we consider pro-gun arguments as well as anti-gun arguments.” The “pro-gun” arguments he mentions are two. First, that a study by an economist found that states with more restrictions on carrying guns had higher rates of gun violence. The study falls into the ecological fallacy, where population-level attributes are being overlaid on individuals. If the murder rate is lower in a state with looser gun laws, it doesn’t translate into individuals being less prone to gun violence. It just means that there is something at a population level at work. Certainly, we’ve had mass murders with guns in very restrictive and in very loose states. It’s an easy mistake to make, but it’s one that needs to be taken into account when looking at the data.

There are better, more epidemiologically-based studies on gun violence, like these from Harvard School of Public Health. Now, if you still want to listen to an economist, this study by Richard Florida is sounder than the one mentioned by Dr. Hsieh (in my epidemiological opinion). And, please, don’t get confused by Dr. Hsieh’s exchange of the word “violence” for the word “crime” when he says that the study he cites “found the opposite — that liberalizing concealed carry laws reduces gun crime.” Crime, yes, but not violence. Violence includes suicide, and there are twice as many suicides as there are homicides in this country, with half of them being committed through the use of a firearm. So, in essence, there are as many suicides by gun as there are homicides by any method in this country. This is a fact we cannot deny, and suicide is most often the result of a mental health condition, which is a medical problem, which is a public health problem when it affects us all (as it does).

Dr. Hsieh’s third point is that “expanding “public health” to include “gun violence” diverts us from genuine public health threats.” What are those threats?

“Meanwhile, Americans are relatively unaware of growing threats posed by drug-resistant “super bacteria.” The recent measles outbreaks show the need greater discussion of the pros and cons of childhood vaccinations for such preventable diseases. Tuberculosis is becoming increasingly difficult to treat, even with our best medications. Regardless of where one stands on the issue of immigration, there are legitimate and serious issues of how the federal government should screen for communicable diseases in people seeking to enter this country.”

In the United States, especially if we keep up the vaccination rate and proper use of soap and water, our children need not worry about measles or about a Staph infection at school. Yet more and more schools are being forced to enact plans to respond to guns in schools because there are kids who are having easy access to guns at home. Dr. Hsieh may not think of a school shooting as being worse than an outbreak of measles or the flu in the same school, but it is. Children dead from a gunshot don’t quite recover like children who get the flu. You’re also far more likely to die if you get shot than if you get measles.

And don’t get me started on the whole “immigrants and disease” thing. Or do get me started, but then read my thoughts about it.

Dr. Hsieh then kind of reveals his apparent disdain for the natural progression of public health as a science:

“There are some who argue that “public health” is not just limited to the spread of diseases, but also includes so-called “social determinants of health,” such as “inequality, poverty, and education.” This is how they try to include issues such as “gun violence” or “climate change” as part of “public health.””

There are not just “some” who argue this. There are “many”, and they are public health and public policy experts from all walks of life and from both sides of the political spectrum. They differ in how to attack the problems, but they know that it’s where you live that determines your health outcomes more than who you are. And, on the issue of climate change, the evidence is there that warmer weather is causing the spread of tropical diseases beyond their endemic borders. As the climate changes and severe weather causes more flooding and infrastructure damage, the public’s health will be undoubtedly affected.

His final point is more of an opinion than his other opinions. A doctor mentioned that guns are his “natural enemy” because they kill, while a physician is supposed to heal. Dr. Hsieh counters that “guns regularly protect good people from criminals.” He offers one instance of someone defending themselves with a gun from a home intrusion to make his point. But I’d like to ask Dr. Hsieh if the instances of people being hurt or killed by guns are higher than those of people being protected by them. I think he knows the answer, and so do I.

The thing that “cut me to the quick” is that Dr. Hsieh is a physician, a partner — if you will — in trying to keep the public safe from any harm that comes their way. Certainly, there are many harms, and our priorities seem a little messed up at the time in the current political climate. Yes, there are more cases and more deaths from obesity, heart disease and diabetes than there are of homicide by gun. Both are very preventable, but we seem to be doing nothing about guns. Even when the American public overwhelmingly wanted universal background checks as a first “baby step” toward sensible gun control, the National Rifle Association used its influence to prevent anything from being done, or worse.

I expect more from physicians and other people with degrees conferred to them by accredited institutions of higher education. I want a physician to know the meaning of “epidemic” and that it doesn’t stop at infectious disease. I want a physician to know that the social determinants of health are not a far-out theory that only “some” in public health have. And I want a physician to realize that it is not bad practice for a physician — or other healthcare provider — to ask about guns in the house. What if the family doesn’t keep them away from children? What if there is a new child coming into the family? Conversations about guns and other dangers should be had between providers and their patients.

If Dr. Hsieh is so worried about “medical freedom”, then he should really be worried that physicians are not allowed to talk about guns with patients in Florida. Using Dr. Hsieh’s freedom logic, legislatures will be in full control of what physicians can talk to their patients about. They’re even doing it in Pennsylvania, where, surely in an anti-abortion mood, the legislature is giving a script to physicians to read to their patients when the patient is found to be pregnant with a child with Down syndrome. That is the “public health” you should put in quotes, Dr. Hsieh, that’s the medical freedom you should fight for.

Don’t fight for the freedom of guns. Guns are not people.

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René F. Najera, DrPH

I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
About History of Vaccines: I am the editor of the History of Vaccines site, a project of the College of Physicians of Philadelphia. Please read the About page on the site for more information.
About Epidemiological: I am the sole contributor to Epidemiological, my personal blog to discuss all sorts of issues. It also has an About page you should check out.

1 reply

  1. Articles like his makes my blood boil.
    Interestingly enough, I happen to own a dozen firearms, some inherited, some historic models, some hunting and competition shooting (you don’t take a competition rifle or pistol hunting, they’re specialized and not built for the abuses that can occur while hunting).
    *All* are under lock and key.
    I remember the Brady law being enacted. Background check for handgun being mandatory (it was in Pennsylvania, but it was with the local sheriff and frequently ended up being delayed by weeks) and a three day waiting period before one possessed the handgun. That disappeared, a background check and out you go with a pistol, ammunition, magazines (if required), holster (if wanted), etc.
    Step both forward and backward.
    Meanwhile, I could before Brady, pick up a rifle, magazine and a thousand rounds of ammunition and magazines and walk out the door with them. After Brady, the same is true. I could, before and after, pick up a shotgun and do the same.
    Granted, a handgun is far more often used to commit violence, but to be honest, a long gun can cause death for a much longer distance.

    Don’t get me started on children accessing a firearm. Or on “accidental” shootings. To me, that is nothing but criminal negligence (or should be criminal negligence). Firearms should be *required* to be under lock and key. A cheap handgun safe is a strong lock box that can be bolted to the wall or floor and costs from $30.00. A fancier model can cost a mere $100.
    A handgun costs a *lot* more than that. My competition firearms cost a *great* deal more.
    Expensive things should be protected. Potentially dangerous things even more protection should be utilized. Potentially dangerous and expensive things most obviously require protection with strong locking systems.
    A sock drawer most certainly does not qualify as protection. Neither is a shoebox under the bed. Nor a shelf in a closet.

    Now, you mentioned diabetes and obesity being an epidemic. You missed that the approach to resolving the epidemic isn’t exclusively medical, it’s social in nature. Many medical issues have had social approaches, vaccination programs are an excellent example of that.
    So have the various STD outbreaks resolution, with social programs ranging from condom distribution to educational advertisements and posters.
    Indeed, the spread of HIV/AIDS was assisted by the discouragement by Reagan of utilizing social educational programs to slow the spread of the virus until it became a significant epidemic.
    Of course, that tends to prove one point I’ve long made.
    If you have a problem and want to royally screw up resolving it, let a politician handle it.
    Politicians are experts at little other than being politicians. Politicians tend to listen more to other politicians, rather than listen to subject matter experts. Politicians will also tend to do that which is more popular, rather than the right thing. After all, the politician has one goal most people share, they want to keep their job. Hence, they want to be reelected. Not doing things that are popular is not conducive to achieving the goal of reelection.
    Regrettably, when matters of public health and safety become of import, we’re stuck with not permitting the experts in those fields handle the issue. Politicians handle it.
    Leaving us to ignore outbreaks until they become pandemics, leaving us to strip search grandmothers, toddlers and mystical no-fly lists (I know of US CENTCOM personnel who had to have the CENTCOM commander call the TSA leadership to have those personnel deploy overseas).

    How do we resolve such a mess?
    To be honest, I have no idea. I sincerely doubt we’ll suddenly start electing leaders who trust and follow the suggestions and guidance of subject matter experts. Our history suggests the opposite.


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