This post is a part of our Bioethics in the News series
By Sean A. Valles, PhD
This year’s presidential debates drew attention to gun violence in Chicago, as well as the (merely?) short-term reversal in the decades-long decline in US violent crimes. In the process, it reignited the smoldering political dispute over whether gun violence is a public health problem.
Every year, US hospitals and morgues see a stream of around 32,000 preventable deaths and 67,000 preventable injuries from guns. Indeed, hospitals and morgues are where one finds the consequences of public health problems. Yet, Surgeon General Murthy nearly had his Senate confirmation blocked by National Rifle Association lobbying in 2014, because he had once Tweeted: “Tired of politicians playing politics w/guns, putting lives at risk b/c they’re scared of NRA. Guns are a health care issue.” The debate continues.
Neglecting the medical and public health aspects of gun violence is a tragic lost opportunity to understand and respond to gun injuries and deaths. For example, only some jurisdictions require special permits to purchase handguns, but public health data indicate that adopting such polices helps to prevent both suicides and homicides. Thanks to NRA lobbying (again), the Centers for Disease Control is prohibited from doing any research that serves “to advocate or promote gun control.” The researchers who dare to work in the under-funded field “face emotional and financial demands” (Pettit 2016). Meanwhile, the 14-year-old National Violent Death Reporting System, the federal database for gun violence, still has zero data from ten states.
“Health in all policies”
Though its hands are partly tied, the CDC endorses the mainstream public health position that we must promote “health in all policies.” I.e. gun policies are (failed) health polices because the US continues to be plagued by gunshot wounds. Health is shaped by all manner of different causes, including laws and policies that were not explicitly designed to be health policies. For example, local commercial/residential zoning laws are public health issues. Why? Because they control the distribution of supermarkets, fast food restaurants and liquor stores in each neighborhood, affecting what the local population can/does eat and drink. Poorly designed city zoning laws are public health problems because they keep nutritious foods inaccessible and less nutritious alternatives abundant.
‘But, if guns are a public health problem then that would mean…’
The notion of promoting “health in all policies” has—surprisingly—faced some of the staunchest resistance from professional public health ethicists. Perhaps best illustrating the divide, the American Public Health Association has co-signed a letter with 57 other medical and public health organizations, calling for expanded gun violence monitoring data and gun control measures. Meanwhile, the ethics section editor of the association’s journal has opposed adding crime and other social ills “to the public health agenda”—doing so would make “public health… so broad as to be meaningless” (Rothstein, 2009). Similarly, an influential public health justice text resists calls to treat crime, war and various other social problems as public health problems, arguing that despite the desirability of a “broad scope of public health,” recognizing them as such would leave public health with “no real core, no institutional, disciplinary or social boundaries” (Powers and Faden, 2006).
Outside of the bioethics community, physician and free-market economics advocate Paul Hsieh echoes the idea that treating guns as a public health problem makes ‘public health’ unrecognizably broad, and it also “diverts us from genuine public health threats.” He scoffs that next we could even start thinking of issues like minimum wage and poverty as public health problems. Funny he should mention it; in fact, small differences in income are associated with drastic differences in life expectancy. An American man in the richest 1% has a life expectancy 14 years longer than a man in the poorest 1%! We now know that the causes of death and illness are complex and far-reaching—we must resist the urge to squeeze “public health” until its boundaries are neatly compressed and its efforts are hopelessly hobbled.
When the American Medical Association issued a statement in July that it considers guns “a public health crisis,” Keith Ablow, a member of the “Fox News Medical A-Team,” retorted that we don’t really know how many homicides could be prevented with gun control. But then he went on to say “they’re going to eat away at gun rights with medical research.” Like the NRA’s efforts to restrict CDC gun violence research, it appears that Ablow is very worried about what gun violence public health data would reveal. It would seem that he finds gun violence research more frightening than… gun violence.
It doesn’t have to be this way
But isn’t it foolish to think the medical and public health communities could help with a massive social problem like gun violence? It’s the reply I hear most often, and it always strikes me as an odd moment of pessimism. Odd, that is, in light of the widely-embraced moonshots of eradicating smallpox from every population on the planet (done!), and spending incredible sums to find treatments for the innumerable and mysterious varieties of cancer (optimistic!). Why do I so often see resigned shrugs when I insist we can make public health progress in the problem of Americans using guns to kill ourselves and each other almost five times more often than our Canadian neighbors? After all, when pediatricians talk to parents about gun safety during a child’s checkup, the parents become more likely to use a gun lock, which substantially reduces risks of gun accidents and gun suicides. Sounds like a good start.
We can do better, and some of my bioethics colleagues have been producing excellent work, making the case for why the deep-rooted social problems (violence, poverty, etc.) causing our public health ills must become national public health priorities, and also priorities for individual physicians. The first step though, is admitting that the roughly 100,000 people shot in the US each year each have gun violence medical problems, and that we in the US have a gun violence public health problem.
Sean A. Valles, PhD, is an Associate Professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. He is a philosopher specializing in ethical and evidentiary issues in contemporary population health sciences.
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