Violence as a public health problem, an infectious disease, and a conquerable demon

I told you the other day about my thoughts on gun control and gun violence. My thoughts boil down to what I mentioned in a comment: I’m not about getting rid of guns. The solutions to problems like these is not one extreme or the other. As someone said during an interview about the Oregon shootings, “The choice shouldn’t be between doing something and doing nothing at all. Doing nothing should not be a choice.” I think that this is something that reasonable people can agree on. There are thousands of deaths from gun violence in this country, and we need to do something about it.

The first question that is usually asked when people in public health want to do something about gun violence is whether or not gun violence is a public health problem. It is. Unequivocally, gun violence is a public health problem. People are dying and being hurt by gun violence. In fact, there is good evidence that deaths from gun violence are about to outpace deaths from car accidents, something you only see in war zones. (Gun deaths already outpace motor vehicle deaths in Michigan.) When we saw that thousands were being killed in automobile accidents, we instituted some common sense laws to make cars safer and to make the people operating those cars operate them safely.

But the National Rifle Association tells us that the comparison between guns and cars is not a good one to make:

“Just as lacking in resonance is the anti-gunners’ theory that government regulation reduced deaths involving vehicles, so the same ought to be true for those involving firearms. From 1981 through 2013 (the first and last year of data reported by the federal government), deaths due to accidents involving “unregulated” firearms decreased 73 percent, while those due to accidents involving highly-regulated motor vehicles decreased only 31 percent. And, two-thirds of the decline in motor vehicle accident deaths has occurred during the last six years, a half-century after Congress imposed the National Traffic and Motor Vehicle Safety Act, authorizing the federal government to dictate how cars should be manufactured and roads should be constructed.”

Of course, the operative word in that whole article by the NRA is “accident.” They compare accidental gun deaths to car accidents and find that there is no comparison, as their thesis seems to be that we should allow more people to have guns because they’re less likely to have accidents with those guns. But that logic is flawed because we’re comparing deaths to deaths, no matter the manner of death. And we do this because a death is a death, and because defenders of the rights of guns keep telling us that traffic laws only stop “good people” from doing bad things and don’t stop “bad people” from doing bad things.

That “good people” versus “bad people” argument holds water if we are to believe that only bad people commit gun violence. If you look at the data — data that is sound but incomplete because of Congressional bans on gun research — you’ll see that the biggest proportion of people dying from gun violence die from suicide by gun, and that there is a strong correlation between owning a gun and the risk of suicide by gun:

“A study by the Harvard School of Public Health of all 50 U.S. states reveals a powerful link between rates of firearm ownership and suicides. Based on a survey of American households conducted in 2002, HSPH Assistant Professor of Health Policy and Management Matthew Miller, Research Associate Deborah Azrael, and colleagues at the School’s Injury Control Research Center (ICRC), found that in states where guns were prevalent—as in Wyoming, where 63 percent of households reported owning guns—rates of suicide were higher. The inverse was also true: where gun ownership was less common, suicide rates were also lower.”

Of course, correlation does not equal causation, but we can’t exactly randomize people into a group with guns and a group without guns and leave them alone to see what happens. But that research did adjust for almost all confounders. In essence, all things being equal, you have a higher risk of offing yourself with a gun if you have a gun, and that makes sense. People who are suicidal and have a quick and available way to do it won’t often think twice about it. “It’s like turning off the lights,” someone once said.

Whenever I bring up these kinds of facts, people who want to protect guns more than protect children in classrooms tell me that gun violence is a mental health issue. After all, only people who have mental health issues kill themselves, right? This leaves out the fact that impulsive people — like teenagers and adults with not-fully-cooked brains — do impulsive things. If they lack conflict resolution skills, they just grab the gun and end the conflict. If a “patriot” sees a cop coming to their home, they might think, “This is it! Obama is coming to get my guns!” And then what happens?

The next move from people who think a few massacred children here and there is a good price to pay for liberty is that someone who is suicidal or homicidal will use just about anything else for violence. “The gun is only a tool,” they say. Yeah, but it’s a very effective tool. If you’re a “patriot” and see the police coming to your door, and all you have is knives, you’re not exactly going to “stand your ground” and take out someone who is just there to let you know that stolen car has been found. And if you’re on the road and someone cuts you off and you don’t have a gun but are prone to violence, about the only thing you can do is throw your car at them.

“Ha! You admit that cars can be used as weapons too!”

Well, yeah, but cars have been engineered to withstand some pretty good licks. Those engineering controls didn’t appear out of thin air. It wasn’t until car manufacturers met a combination of laws and regulations and really expensive lawsuit settlements that they decided that maybe it was time to make cars safer, putting in air bags and checking their brakes for quality. Unfortunately, we cannot ask the same of gun manufacturers. They have complete and impenetrable liability protection:

“The Pavelka family filed a lawsuit against the gun dealer who sold the guns used to shoot Matthew [a cop], arguing that the dealer did not take reasonable steps to prevent the sale of the firearms to the straw purchaser who likely intended to resell the weapon on the black market. In an ordinary case involving any product other than guns, the family could have gathered evidence and subpoenaed witnesses to build their case and learn more about the sale. Yet the family’s suit was dismissed almost immediately thanks to a special legal immunity that Congress gave gun manufacturers, distributors and dealers, and their trade associations, in 2005. Unlike any other industry, the gun industry can commit negligence with impunity.

In 2005, when Congress passed the Protection of Lawful Commerce in Arms Act, granting the gun industry immunity in state and federal court from civil liability in most negligence and products liability actions, the National Rifle Assn. called passage “vitally important” and fought hard for it. Although there are exceptions in the law, it has been broadly interpreted to preclude most negligence lawsuits. The result is that — unlike the makers of chain saws, knives, automobiles, drugs, alcohol or even cigarettes — gun manufacturers and sellers have a lesser obligation to act with reasonable care for public safety.”

Yes, ladies and gentlemen, the National Rifle Association protects guns to the extreme that reasonable engineering and sales controls to prevent police officers from being shot cannot be forced upon gun manufacturers. If we are to have things like serial numbers that cannot be erased, background checks on all sales of firearms, and ammunition that tells you exactly which gun fired what bullet, we need to sit around and wait for gun manufacturers to put these things in place out of the kindness of their hearts. We are really lucky that the auto industry didn’t bribe legislators into having a similar bill back in the 1970s or we would have never seen the big reduction in vehicle deaths that we have seen because car manufacturers were forced into giving us seat belts, air bags, and good brakes.

That protection of gun manufacturers by legislators who drool at the sight of a wad of cash in their coffers and laugh at the idea of saving college kids from being shot in the head one by one is exactly why the whole theory that only “bad people” would have access to guns falls flat. If bad people have access to guns, but we had engineering and sales-tracking controls of guns, we would be able to find those bad people and punish them so harshly that they idea of owning a gun would make them sick to their stomach. Or we would avoid them from getting those guns to begin with in a lot of cases. (Not all cases. Let’s not fall for the Nirvana Fallacy here.) But we don’t even get that, and families of slain officers and regular citizens have lawsuits that “have been dismissed on the basis of the law, even when the gun dealers and manufacturers acted in a fashion that would qualify as negligent if it involved other products. Victims in these cases were denied the right to introduce evidence of negligence and seek justice.”


But let’s switch gears 1,500 words into this blog post and talk about violence in general and how we in public health are starting to see it as something more akin to an infectious disease which has a mechanism of action and can be preventable. (Though it can’t be grown in a petri dish.)

welcome_phil_rogers_guns

Image derived from “Welcome” by Phil Rogers via Flickr, CC by -NC 2.0

There was a workshop in 2013 on the “contagion of violence.” From the summary:

“Violence is a contagious disease. It meets the definitions of a disease and of being contagious—that is, violence is spread from one person to another. This paper will clarify (1) how violence is like infectious diseases historically by its natural history and by its behavior; (2) how violence specifically fits the basic infectious disease framework—and how we can use this framework to better understand what is known of the pathogenic processes of violence; and (3) how we can provide better guidance to future strategies for reducing violence, in order to get more predictable results, and develop a clearer path to putting violence into the past.”

As an epidemiologist, I found this to be fascinating. The rest of the paper makes sense to me because the epidemiological terms used for infectious disease investigations can be applicable to violence. If you are the victim of violence, you are more likely to be violent toward others. Or, if you live in a violent home/neighborhood/society, then you are more likely to be violent toward others. Thus, violence is contagious.

Violence is also preventable. (I wish it were as easy to prevent as giving someone a vaccine.) Through information, education, and engineering controls, we can prevent most of the violence that happens anywhere. Sure, it takes a herculean effort, but it’s not like we haven’t come together on other Manhattan Projects before. Yet, before we can do something that is effective, we need to know what the size and scope of the problem is. When it comes to gun violence, politicians who tear out the Second Amendment and save it while using the rest of the Constitution as toilet paper have tied the hands of the Centers for Disease Control and Prevention — as well as other agencies — by limiting the amount of gun violence research that can be done.

This is not to say that nothing can be done. As you saw above, public health institutions are looking into the association of guns and violence to things like suicide. Lucky for us, there are people who don’t want to see the world burn, people who see those who do want to burn down the world and swear that we will fight them with everything we’ve got.

So let’s start at the beginning in dealing with violence as a contagion. First, let us confirm the diagnoses and establish our baselines. Then we determine who is being affected and how. And then we evaluate our interventions so far and the interventions to come. If all of that sounds familiar to you, it should. Those are the functions of a public health surveillance system.

I hinted at a surveillance system for violence a while back when I was telling you about the new epidemiologists. This is because I’ve been looking at such a system as the basis for my DrPH thesis. I’m thinking that, if we use the tools of epidemiology in general and disease surveillance in particular, we can come up with some really good information and ideas on how to conquer the demon that is violence in this country.

Take, for example, this graph of criminal incidents in Baltimore:

Don't look too closely at the average. I'm still working on that part.

Don’t look too closely at the average. I’m still working on that part.

Notice that there is a dip in crime that starts toward the end of the year and ends around springtime. One thing that I have noticed is that the media reports “surges” in crime between February and April, then just pretty much become “numb” during the rest of the year. When those “surges” occur, politicians come out and proclaim their latest, greatest crime prevention program. Federal, state and local police agencies tell us that they’re working together to stop it, and that the criminals will not win. Then crime levels out at a higher level and dips again in the fall.

Of course, if you see historical data and put the current surges and dips into context, you would understand that something else is working to influence crime levels. You might even be tempted to say that the surges and dips are “expected,” something that politicians would try to stay away from saying. But, if you look at the evidence, this up and down pattern has been repeating itself for a while now.

It almost looks like the flu season graph of pediatric deaths by year, doesn’t it?

Yes, it comes off as callous to say that we expect a certain number of deaths from influenza or any other disease each year. But we in public health don’t say that in a vacuum. We say it because we want the public to understand the past, current and future situation. If we see a surge in crime in April and say that it is expected, it’s not to belittle the efforts of the police. It’s to keep the public from panicking. Nothing good happens when you panic.

Also, there is a little bit of an element of pressure on the authorities when we say that we expect a surge in crime. It’s a way of telling them that something is coming and that they better get to it before it happens, just like we tell people to vaccinate — and institutions to offer the flu vaccine — well before the flu season that we know is going to come.

A proper surveillance system that looks at crime patterns and trends would help as an “early warning system” of sorts to alert the authorities that, based on previous years’ data, we are about to experience a surge in crime. This way, with a few weeks warning, things can be put into place to minimize the surge, just like we do with the flu vaccine each year.

Violence of all kind, but especially gun violence, is a huge public health problem in the United States. There are plenty of other democracies with similar values and institutions as ours where mass shootings are unheard of. The common denominator in gun violence incidents are guns, but our elected leaders seem to be more about protecting the rights of guns to exist. Simple, common sense fixes can be put into place that would not take away anyone’s guns. Instead, guns would be safer, and the people who own them would use them in a safer and more responsible way. Furthermore, those who would use guns for a nefarious purpose against others (or against themselves) would be kept away from guns, but politicians can’t even come together to prevent dangerous (not good or bad) people from obtaining guns, and engineering controls are not being put into guns by manufacturers because they don’t have to and no one is telling them to.

The good news in all of this is that more and more public health researchers, workers and policymakers are coming to the conclusion that violence can and should be treated like an infectious disease. There are plenty of prevention efforts that could be adopted to prevent violence, and there are plenty of “outbreak” response-type efforts that could be deployed to counter violence. It all starts with surveillance, though. A good surveillance system — like the ones deployed already in Colombia and Mexico City — can give tons of reliable information to decision makers, public health and public safety to attack violence and crime before what is expected comes true.

  1. Compare criminal violence with socioeconomic conditions, one will see an increase there.

    But, far too often, people compare ownership and operation of a motor vehicle with ownership and operation of a firearm.
    They fly off of the wire (a term derived from wire guided antitank missiles) there, for they compare a privilege that can be administratively revoked with an enumerated right.
    Fortunately, those actually trying to study the problem have largely failed to fall for that trap.
    It’s especially pleasing to see that some are indeed studying the major problem that this nation has, despite a bought and paid for Congress (hey, the last two elections ran to the tune of eight billion dollars, that money came from somewhere and sure wasn’t the populace, unless corporations are indeed people).

    Full disclosure, I personally possess more firearms than I have limbs, some are inherited and are of historic interest, others are competition firearms and some are for hunting. Annoyingly, I’ve not had the time to compete for intermediate range precision competition for the past five years, but once my relocation has completed, I intend to reenter competition. The only tyranny I fight against is the tyranny of an unperforated center ring on concentric circles on a piece of paper, winning a turkey or ham during the holiday season or cash prize on other occasions.
    Home defense is conducted with quality locks and egress points, as what I have of value really is only my own butt and my wife, the expensive computers are too impractical for a thief and my consumer electronics are either unwieldy to steal or too cheap to worry about.
    I had more than my fill of violence in my military career and my firearms are stored in firearm safes that are bolted to the frame of my home. By the time those are prized away from the frame of the house, any tardy police will have long arrived to greet that incredible hulk and take that individual or individuals away where harm is only done to prison meals.

    So, please keep researching, the populace is interested, if not what this multiple firearm owner calls freely “gun nuts” and the industry.

    We’ll be still in Maryland until at least the end of the month. Still waiting for that beer, Rene. 🙂
    Unfortunately, I’m on midnight to 8 shift, but I’m sure we can find time on a weekend.
    Now, I’m off to replace a lost social security card, to prove to the company and our government that I really am not an illegal alien. The I9 process is a royal pain in the asterisk.
    Then, I have to catch some rest, midnight comes awfully early these days.

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  2. One question, during the peaks and troughs, what were the weather conditions?

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    1. Hot and cold, respectively. And, yes, I know where you’re going on that one.

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      1. I suspected it was miserable during the troughs, after all, even the most dedicated criminal or insane person or any mixture in between that might cause a problem (yes, I know that the most minuscule number of the insane try to harm others, but that number is still greater than 1) when it’s *really* uncomfortable out.
        I imagine that in extremely hot regions, when it’s 120 – 130 degrees out, crime falls into the basement as well, again, too extreme to be out and trying to be extreme.

        Likely, low or no precipitation days also had spikes in violence, again not wanting to be out and soaked to the skin.

        The causes of much crime are a complex set of conditions, grinding poverty, no escape route from that poverty, poor or indifferent education also eliminating escape from that poverty and forget about finding the largely migrated away jobs. Every inner city has those very same social ills.
        Add in lousy press coverage, being called “those people” day in and day out, all sense of self-worth and community disappears.

        One gains a lot of perspective when one lives in a rough neighborhood, travels socially to worse neighborhoods and actually listens to what is being said and left unsaid.
        Ask me some time about my town watch building.
        Preferably over a beer or two.

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