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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References
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- Media Matters Staff. 2016. “Fox Medical A-Team Member To American Medical Association: “Shut Up” Over Gun Violence As Public Health Crisis.” Media Matters. accessed 11/9/16. http://mediamatters.org/video/2016/06/17/fox-medical-team-member-american-medical-association-shut-over-gun-violence-public-health-crisis/211012/.
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MSU Bioethics 
Dr. Valles,
Thank you so much for your insight, and powerful message regarding our country’s gun violence public health problem. I am a social work graduate student at Michigan State and personally am very liberal; I have never felt passionate about the second amendment nor will ever have the desire to own a gun. But your data and facts are all true, your message is clear, guns are too easily accessible in our country, and it is causing a staggering number of avoidable deaths annually. This makes me so concerned that our country is still refusing to acknowledge it as a public health issue. It tells me that the people in power, who are meant to protect us, are ignoring the serious harms that come with having an overabundance of firearms in our nation from its easy accessibility. With the change in our nation’s elected officials, the NRA is going to have more power than it ever has before, which makes this even more frightening.
When you mentioned the NRA preventing the CDC from researching this topic, you suggested, “It would seem that [Ablow] finds gun violence research more frightening than… gun violence.” That is an interesting point, and I wonder why they are so afraid of the research? Personally, I feel that the NRA should not have the amount of power that they do to levy their influence over the Centers for Disease Control. It seems absurd. The NRA has created and is reinforcing an even more detrimental reality in our nation, which with proper regulations could be all easily reduced and managed.
Thank you to you and your team for the great work you are continuously doing to in attempt to get this serious message heard with your persuasive cases and statistics. Change cannot happen overnight, but it’s got to start somewhere, which is by first accepting gun violence as a public health problem. Nicely done.
Thank you very much! The politics of coming up with effective solutions are daunting, all the more so in the current political climate. But I am optimistic that we can move forward in the process by making the conversation about something other than the Second Amendment. Yes, it is the supreme law of the land. Yes, it has multiple legitimate and contradictory interpretations. Yes, the Supreme Court has favored one of the interpretations. Granted. That has nothing to do with whether or not the tens of thousands of gunshot wounds every year add up to a public health problem. I have a hard time seeing how they don’t. Solutions will be hard, but I think the US has the fundamental ability, even in this political climate, to recognize the problem as a public health problem.
Thank you very much! It appears my last attempt at a reply to your comment did not work. In any case, as I say in another reply below, it is good to see yet another social worker (the under-appreciated front line of the health system) taking an interest in this issue. I am discouraged at the prospects for coming up with effective solutions in the current political climate. But, I remain optimistic that the US is ready to recognize this as a health problem. Parsing the technical meaning and legal limits of the Second Amendment is a debate that will need to continue. But that’s a matter of which solutions are possible, and we need to first agree as a nation that there is indeed a public health problem at stake.
Thank you for the insightful blog post, Dr. Valles. Personally, I do feel that things like gun violence will gradually be seen as a public health issue. As a social work intern at a mental health hospital with patients who are suicidal or have suicidal thoughts, I am constantly told to look at the biological, psychological, and social forces that influence a patient’s health. This is particularly true during the intake process. We specifically ask if a patient has access to guns in the home. Until those guns are removed or locked up, our doctor often will not discharge a patient because of safety concerns. Like the parents who are spoken to about gun safety, I feel like this sort of awareness and education is being built into the health culture. I am hopeful that the same is true about social issues like poverty. If a doctor could write and fill a prescription for healthy food, I think a lot of public health issues would be solved.
I understand the worry that healthcare and health policy may lose some of its focus if it begins to be integrated into every policy issue. And yet, if data supports the intersection between health and gun violence, it must be advocated for by health professionals. Do you believe the research limitations exhibited by the NRA will have a strong impact on the relationship between gun violence and health policy? Or will other organizations be able to come forward and fund such research? Once the data has been gathered, I hope that more people will align themselves with the cause.
Thank you! Your experience with this issue is especially relevant, since there is such a plain risk of harm to certain patients being discharged. And your point about prescriptions for healthy food is well taken. Right after the post came out I saw this short but clever article on 538.com, “Why Don’t Food And Housing Count As Health Care?” (http://fivethirtyeight.com/features/why-dont-food-and-housing-count-as-health-care/). Indeed, US health has many problems, not least of which is the ideology that health care is just that-which-doctors-prescribe. If we started seeing health as something more social in causes and solutions then perhaps we could finally start paying social workers, like yourself, something more befitting the crucial role they play in promoting health :-). As far as whether other funding sources will step up to fund gun violence research to compensate for federal restrictions, it seems that not enough have. The Pettit article I cite from the Chronicle of Higher Education is just a few months old, and it described the situation as “a trickle of funding.” Things were looking up when the article came out in August. Much will change soon, though.
Thank you for the thoughtful and well researched article, Dr. Valles. I appreciate the perspective of gun violence being more than just a gun control problem, but rather an issue of public health. This is not a perspective that I had heard, nor thought of, before, and is rather refreshing.
I am also a graduate student pursuing my masters of social work, and I am also earning a certificate in healthcare at the same time. What lead me to want to pursue a healthcare certificate was my experiences as a direct care worker at an adult foster care facility and a nurse aide at a hospital. While at the hospital I cared for a patient who had been shot in their abdomen, in the same spot, for the second time in their life. This person did not have health insurance but was fortunate enough (or unfortunate enough, because of the length of their stay, depending on how you view this) to qualify for emergency Medicaid. This person was in the hospital’s care for more than 45 days and their medical bills were into the millions of dollars. There is no way this person, or any person who isn’t well-off, would be able to pay off this bill without either declaring bankruptcy or having the best insurance out there (which they did not have).
Being unable to pay medical bills is not a new phenomenon, but is becoming a more prominent issue in our society with increasing medical costs and people not being able to afford health insurance. When people cannot pay their hospital bills, someone has to make up that cost, and, from my research, the cost is either passed along to other insured patients or is paid by the government (taxpayer dollars). This causes both costs of insurance and taxes to increase. Because some of these hospital bills are paid by taxpayer dollars, and I’m sure some of those bills are for gunshot incidents, gun violence is certainly an issue of public health. To say that gun violence is too broad to include in the spectrum of public health, according to this logic, is absurd.
Yes, the financial costs of inaction are high. In the case of smoking, society came to realize that they were literally paying for the harms of tobacco companies’ products. Perhaps that is reason to be optimistic that a similar interest in financial accountability will lead taxpayers to scrutinize gun manufacturers for their roles in a costly public health problem.
Dr. Valles,
Your articles really brings a lot of different things to perspective. I am an avid supporter of our second amendment but I do agree that it needs to be more regulated. A gun owner should not be able to apply for their firearm and receive it within the same day, in my opinion. I believe that firearms safety conversations can make a big different when it comes to “accidents” with firearms. I like that you brought up a pediatrician discussing firearm safety with new parents. I was lucky enough to be raised by my father who taught me basic gun safety and responsibility but a lot of people are not that lucky. So they get a pistol and don’t think it have it in a locked case away from children because no one ever had that conversation with them.
If gun safety and control was made a public health problem, I do believe that a lot more of those conversations would be happening. I also liked that you addresses that violence isn’t the only reason we need gun control. If a gun was properly locked away in a case or gun safe it would be a lot less likely for someone to commit suicide with that firearm. I am interested to see where the push for making this a public health problem will go. I do agree that there become a point where you can’t include everything but at the same time it really is a public health problem.
It is so encouraging to hear that an “avid supporter of the second amendment” found the argument credible! And it’s also good to see the suicide part of the problem being taken seriously. I far too often encounter people who are firmly convinced, based on intuition alone, that suicides cannot be prevented (which is just false).
Dr. Valles,
Having been raised in a very pro-gun family, I have struggled with this issue. I have always felt that I can understand each side’s argument, and I have done my best to look into the unbiased data as to what the real effects of having/not having guns does to a country. I can see, on the one hand, how increased regulation (and perhaps even banning) would appeal to those who see the murders that have become so much more commonplace in the last 20 years. I can also understand the fears that once the government gets a foothold with gun policy, they will ultimately take away our right as Americans to bear arms.
I am not in support of banning guns completely, and I do have concerns that that is what is really on the liberal agenda. However, I can see the wisdom in common sense regulation. With that in mind, I have looked to other countries who have banned guns – the United Kingdom, Ireland, and Australia – to see what really happens when this kind of legislation is enacted.
In most of the more unbiased sources I found, the data shows that gun bans don’t really make a difference in the overall number of murders and suicides. There are statistics out there that seem to say otherwise, but as I understand it, those statistics are usually based on only gun-related murders/suicides, not the rate of murders/suicides overall. Some of this is due to the fact that it is fairly easy to manufacture guns and ammo at home. The materials are widely available (and cheap). Banning guns also creates a huge black market, historically. For me, this sheds a lot of light on the issue. I believe the arguments on both sides are wrong. The data show that banning guns tends to create a temporary spike in violent crime post ban, and then the violence returns to its baseline level. This has been true in all 3 countries mentioned above (at least as far as I know). I think the issue is related more to education an poverty, which is more highly correlated with violent crimes.
All of this being said, I just want to make it clear that I’m not trying to be disagreeable for the sake of disagreeing. I’m also only going on what I’ve read, which have appeared to be reasonable and unbiased sources. I’m open to being wrong though. I also realize that you haven’t actually mentioned banning guns, just looking at gun violence as a public health issue, which I think is valid. I was just a assuming that you were in favor of more gun restrictions. I did find one source that mentioned utilizing proactive arrests and revoking concealed weapons licenses from criminal offenders as being effective in reducing the overall crime/violence in Kansas in the 1990s. This is legislation I would be in favor of.
As with most issues, this one is very sensitive and difficult. I think it’s an emotional issue for people, and we’re all trying to fix the problem in the best way we know how. I have never thought about gun violence as a public health issue, and I appreciate your insights into the issue.
This is surely the most civil conversation about gun violence and gun control that I have ever seen! Thank you for keeping up that pattern!
I intentionally did not leap to advocating for comprehensive gun restrictions. I am more concerned with changing the gun violence conversation, since a key dimension of the conversation (health) has been left out. Banning guns entirely is not a plausible solution and I have little interest in debating its merits. That said, it is hard to infer the benefits/drawbacks of any potential US gun control measures when we are such a bizarre anomaly in so many respects. As seen in Table 4 here, compared to other wealthy nations, our rates of gun homicides are over 7 times times higher than the next highest country’s. But, our non-gun homicide rate is also the highest compared to every peer country except the Czech Republic. It pains me to admit, but we are an anomalously murder-prone country. So, it is hard to know whether our homicide rates would stay relatively stable after imposing strict general gun restrictions (as they did in Australia) or whether they would decrease. I suspect that our rates would be more amenable to reductions partly because we have so much room to improve.
In any case, some potential policy interventions could include measures totally aside from anything resembling bans. Offering gun safety classes for new parents with firearms; providing free gun locks and gun safety training to every gun owner; removing the loophole that allows some private gun sales without background checks; demanding more extensive safety design features on guns; the list goes on. One key task will be massively increasing federal funding to learn what does indeed work. I am foremost concerned about the combination of silence and ignorance about the health dimensions of gun violence.
Thank you Dr. Valles for bringing up great points about this topic. I am also a social work graduate student working towards a certificate in healthcare. To be honest at first I would have never considered thinking about gun ownership or gun safety as a public health policy but it does make a lot of sense. I believe that our society doesn’t want to ask uncomfortable questions especially about mental health and suicide, but it really ties into gun safety in my opinion. I think that there should be more specific screening asking hard questions when someone is trying to attain gun ownership.
I have close members of my family in different counties of Michigan who own guns and it is ridiculously easy to gain access to a gun in Michigan. In fact one of those people has their Concealed Pistol License and attained it in Grand Haven, Michigan. In order to do so they had to go in front of a board and be prepared to answer questions. The questions were similar to “Why do you want to be able to carry a concealed firearm?” “Do you have any issues with anyone?” And “Do you have any criminal history?”, however, the area stopped doing the board questioning a few years ago. I also think it would be valuable to do more screening for domestic violence offenders, this type of a screening would probably be easier with a waiting period between when you purchase the gun and when you receive it. That would also probably be valuable for preventing deaths by firearms.
I think that by changing the topic of gun violence/safety to one of public health, it might be able to change the perspective on how people view the mental health issues that I believe should be considered in purchasing a firearm.
Thank you for posting about a great topic!
Thank you for drawing attention to the topic of intimate partner violence (domestic violence). I really should have discussed that more in the original post. As illustrated in the article below, women are roughly five times more likely to be murdered by their intimate partners when the partners have access to guns, while the victims’ access to guns has little or no protective effects (contrary to some people’s intuitions). Intimate partner violence is a dire public health problem, one which tragically intersects with the public health problem of gun violence.
Click to access 10v.-Risk-factors-for-femicide-in-abusive-relationships-1.pdf
Dr. Valles,
Thank you so much for your profound passion on such a hotly debated topic in the United States. As many of the other students commenting, I am also a social work student in the masters program at MSU. I grew up in a family that never had guns around and was against having a gun in the home. I still carry those values. I like your comments on expanding on what we as Americans see as a public health crisis. When we view a public health problem we see it as strictly medical. However, expanding our view on that and looking at it from a societal lens is imperative. Our societal habits and culture have an influence on our health, whether we would like to accept that or not is another issue. However, what I find most concerning is that despite the over whelming evidence on gun violence, there is still a large amount of evidence not researched, and frankly not allowed by lobbying interests. I think as a country, and an informed voting population we should have the right to the most accurate information available, whether it favored one side to the gun issue or not. The right to accurate information is imperative when it comes to a country making an informed decision that can affect all of its citizens.
The right to bear arms is a constitutional right in this country. However, having accurate information as to how guns are used (good or bad) in this country can give us an accurate picture as to how we as a country use guns. This can then create gun laws and legislation that are reflective, and accurate, of the gun climate we have in this country.
Thank you for your post!
Thank you for the thoughtful note. Yes, I share your view that there is something especially bad with the fact that information has been stifled. It is hard enough to make good policies (of any kind). I appreciate the research that has been accomplished despite the funding limitations, and desperately wish there were more of it.
Dr. Valles,
I appreciate your insight on this topic. Prior to this article I did not view gun violence as a public health issue. After reading this article, I do not know how I did not correlate the two. I grew up in a home that had guns and I was taught early on about gun safety. So I’ve always felt people should be allowed to own guns. I do agree though, that guns are really easy to get your hands on. You can go into a gun store, they run a 30 minute background check on you and you can leave with the gun. I feel like the process could be a bit more complex or have a wait period. Going back to what you said about the pediatrician talking to parents about gun safety, I feel like these talks should be made when purchasing a gun. If not already, I feel that people should have to take a gun safety course before they are allowed to purchase a gun. This might reduce they amount of gun accidents. In general, I do see how gun violence is a public health issue, especially with school shootings. When people are going in to schools with guns it definitely becomes a public health issue.
I like that you brought up the fact that the NRA blocks research from being done. I know they are a strong and very influential group. I agree that more research needs to be done on this issue but I do not see the NRA allowing it to happen. They will do whatever they can to try cover it up or say it is not valid.
Thank you for sharing your perspective on this, as someone raised around guns and gun safety. And, yes, pediatricians’ offices are definitely not the only place where gun safety lessons would be hugely valuable (you pointed out how it would make sense to have the issue raised at the time of purchasing a weapon). I also agree that the research side of things is a little disheartening. But, this may be excessively optimistic, the (eventual) success of reframing smoking smoking as a public health issue gives me hope. Cigarettes continue to destroy so many lives, but even the tobacco industry and its influence were not able to permanently keep the US public from recognizing cigarettes as a public health problem. That’s something…
Dr. Valles,
Your insight on the correlation between gun violence and public health was eye opening. As a social work graduate student and the product of an inner-city environment, I know all to well the societal stress gun violence continues to cause. What I like the most about this article is it informed me of the opposing sides argument. I believe that making public health “too broad” or “leaving medicine out of gun control” is not a big enough reason for medical research to be a part of the gun violence conversation. With such startling numbers of how many people come to the hospital due to gun violence, it is obviously a no-brainer that gun control should be studied within public health.
In the article, you mentioned that the Surgeon General Murthy tweeted about gun violence being a public health problem. Do you think in his role or with his influence he will advocate for gun violence to be a part of health research? Your article provided such a convincing argument that it’s hard for me to not want to know what the future of public health will be like with the incorporation of gun violence research.
Thank you very much for taking the time to reply! It has been wonderful hearing your perspective and your background, alongside the other commenters who had some similarities and some differences in their own ‘angles’ on it.
It looks like Surgeon General Murthy may have perhaps left the issue aside for a brief period of time, but he is back on the issue again and is showing some great leadership on it.
http://www.huffingtonpost.com/entry/surgeon-general-vivek-murthy_us_55f67ab7e4b042295e36b2d1
He, and any other such leader in a federal agency, have only some individual control over things like funding. My sense is that the first necessary step will be getting the public support and understanding behind the very notion of gun violence as a public health problem. Once that happens, much more will be possible.
Hello Dr. Valles, thank you for writing about this topic. I have not previously considered guns as being part of the sphere of public health, but it does make sense as public health concerns itself with contributions to life expectancies, population health, and social risk factors. I understand how some could take “‘health in all policies” as a stretch, but the epidemic of gun violence seems to fit within the schools of public health. I will note that I am using the label of “gun violence” to distinguish from people who responsibly own guns and use them by properly storing them and for hunting, etc. Public health overlaps with many other fields, such as education, social work, and law, and though as you’ve pointed out it is hard to make progress because of various lobbying efforts, I am hopeful that others will be able to see gun violence as a behavior that can be prevented by the collaboration of these fields.
Dr. Valles, thank you for taking the time to write such an amazing article and bring more awareness to this issue in our country. Especially from a public health standpoint, which seems to be not very well recognized until thousands of people end up in our emergency rooms every year due to gun violence, then we’re at a crisis and it’s a medical issue but what about the initial public health issue and concern? To be honest, I have never really given much thought on gun violence being a public health issue, not saying that I don’t agree with this because I do. Even as a social work student, I have initially seen this as a medical problem, but it is certainly more than that.
Education in all realms is extremely important and its going to take social workers and other professionals within the public health realm and even outside of that to bring awareness to this issue and how we can prevent this. Just like the example you gave, with pediatricians talking with parents about gun safety and the impact of that, more professionals could step up just to prevent the many deaths of gun violence. Unfortunately, there is always going to be a downside and crookedness in any situation; with this situation guns are still going to be sold illegally no matter how much education and prevention we do. But it’s a major start and big help towards gun violence in the public health realm. When people know better, they certainly try to at least do better and we can make that happen, I’m certainly optimistic about that!