Interview: Treating gun violence as a public health crisis

“Public health is about prevention,” says David Hemenway, an advocate for taking on gun violence with public health

Published August 21, 2023 6:34AM (EDT)

Handguns that were swapped for gift cards during a Los Angeles Police Department sponsored gun buyback event in Los Angeles, California on December 13, 2014. (MARK RALSTON/AFP via Getty Images)
Handguns that were swapped for gift cards during a Los Angeles Police Department sponsored gun buyback event in Los Angeles, California on December 13, 2014. (MARK RALSTON/AFP via Getty Images)

This article originally appeared on Undark.

Each year, nearly 49,000 lives are lost in the United States due to gun violence, of which more than half are suicides. More Americans died as a result of gun violence in 2021 (the most recent year for which complete statistics are available) that in any other year on record — though due to the nation's growing population, the rate of gun deaths has remained lower than its peak in the 1970s. Youth gun violence, in particular, appears to be on the rise.

For decades, the question of how best to confront the epidemic of gun violence — with policy, law enforcement, education, public health, or a combination — has been fiercely debated and politically contentious.

In 1996, under pressure from the gun lobby, Congress enacted the so-called Dickey Amendment, which prohibited federal money from being used to "advocate or promote gun control," effectively blocking the Centers for Disease Control and Prevention from using federal money to conduct research into gun-related violence. But in 2019, lawmakers brokered a deal that clarified the amendment's intent, approving $25 million in annual funding for the CDC and the National Institutes of Health to study gun violence through the lens of public health.

Now revived, the field is still in its early stages, and so far there is little evidence of common ground between public health advocates and gun rights activists, and others who don't see gun violence as a public health problem. But there are signs of traction: The American Public Health Association, the Association of American Medical Colleges, and the National Institute for Health Care Management have all adopted a public health approach to the nation's gun violence crisis.

"Almost half of our gun stock now is handguns. And we also have all these military weapons that are easy for anyone to get. Then we have by far the weakest gun laws."

David Hemenway, a professor of health policy at Harvard University and director of the Harvard Injury Control Research Center, advocates for the public health approach, which he explored in his 2004 book, "Private Guns, Public Health." "Public health is about prevention," he says, while acknowledging the crucial role of law enforcement. "It's not a fight about finding fault. It's not about finding who did something wrong. It's about trying to figure out ways to prevent the problem from occurring."

While Hemenway is eager to see more research, databases like the National Violent Death Reporting System, which combines police and medical examiner information on all violent deaths across all 50 states and Washington, D.C., and the Web-based Injury Statistics Query and Reporting System, have already proven to be vitally useful, he wrote in an email to Undark. (Both are maintained by the CDC.)

Our interview was conducted over Zoom and by e-mail, and has been edited for length and clarity.

Undark: The United States has a high rate of gun violence and gun deaths compared to other industrialized countries. Why?

David Hemenway: The big reason is the guns and the gun laws. Evidence indicates that we are really an average high-income country in terms of non-gun violence and crime. So if you look at our overall rates of burglary, or robbery, or sexual assault, or car theft, we do better than some of the other high-income countries and we do worse than others.

But where we are different is we have lots, lots more guns; much greater household gun ownership; and also the types of guns we have. Canada has a fair number of long guns, but we have so many handguns; almost half of our gun stock now is handguns. And we also have all these military weapons that are easy for anyone to get. Then we have by far the weakest gun laws.


UD: You're known for supporting a public health approach to combating gun violence. What does that entail?

DH: If you ask me for a one-sentence description of the public health approach, it would be: Let's make it really difficult to get injured, or to injure someone, and let's make it really easy to be safe. So for example, I do some work about obesity, and the public health approach to obesity would be, let's make it really easy for people to get healthy food, and make it harder for people to get junk food; let's make it really easy for people to get healthy exercise and make it harder for them to be couch potatoes. And we do just the opposite in the United States.

The public health approach is about prevention. It's not about individuals; it's about the population.

We now have a good national system about violent deaths. Every time now that there's a violent death in the United States, a homicide or suicide, there's about 120 pieces of information collected, consistently and comparatively, across all the states and over time.

"The evidence in the United States that a gun in the home increases the risk of suicide in the home is overwhelming."

So we're starting to understand more and more about what is happening, what might work, what might not work. And then we try things; you're going to be able to tell, did this really work or didn't this work? So having good data really matters.

UD: It's been difficult in the United States to get federal gun legislation passed. Are there things that can be done at the state or local level?

At the local level, there are so many interesting, exciting initiatives that we think work. Hospitals are having these — it used to be always at level-one trauma centers — somebody would get shot, they'd fix them up and they'd send them back out. And those people are at very high risk for getting shot again or for shooting somebody else. And now what you do is, you have designated entities in the hospital who says, "Oh, someone came in for a shooting; what can we do to make sure to help them so that it's less likely that they will go back and get shot, less likely that they will retaliate and shoot somebody else?"

We have initiatives in Boston trying to reduce the likelihood that women will get involved in gun violence. In the United States, one way that the wrong people get guns is with "straw purchasing.'' So a straw purchaser, basically, you're buying a gun for someone else who won't pass a background check. When a woman buys a gun, she is disproportionately likely to be a straw purchaser, to buying a gun for her boyfriend who shouldn't have a gun.

And what's been happening in Boston is to try to work with women's groups, and women in the inner city and other places, to try to convince them that, look, you should know, and everybody else should know — it should become the social norm — that if your boyfriend asks you buy by a gun for them, illegally, or to hold a gun for them, illegally, you're going to be at real risk. Because if you get caught, you have nothing to trade, because you don't know what's going on, and they can put you in jail — and have put people like that in jail — for many years. And you're also hurting your own community.

So it should be the social norm, that you and everybody else knows, if your boyfriend asked you to do that your response should be "Get rid of that boyfriend," because that's really a horrible, horrible thing that they're doing.

UD: How would a public health approach help reduce gun suicides?

DH: The evidence in the United States that a gun in the home increases the risk of suicide in the home is overwhelming. There are case control studies, there are ecological studies, there are longitudinal studies — they're dangerous to everyone in the house.

Having guns lying around when someone's at risk for suicide is a terrible, terrible thing. We're working now to try to make sure physicians understand that. So if you're a psychiatrist, and somebody comes in, and they're talking [about] suicide, you should ask not only about their mental health and try to help out, but you should talk directly about guns, and try to get the guns out of the house. And if not, I would argue that that's like malpractice, not to do that now, with what we know.

Ten or 15 years ago, nobody in the in the gun area was talking about suicide. They believed, completely incorrectly, that if you want to commit suicide, you'll commit it no matter what, that no one's going to stop you. So my colleague Cathy Barber spent a lot of time working with gun shops, working with gun ranges, working with gun trainers, to try to make a difference about suicide, and has had a lot of success.

Let me talk about the trainers, since that's the most interesting. She got herself invited to this association of gun trainers who were teaching about gun carrying. And you should recognize that Utah is a very red state; it has lots and lots and lots of guns, and very conservative. And she said to these trainers, "You know, you're trying to do a really good job talking about gun accidents, but did you realize that for every accidental gun death, there are 85 gun suicides in Utah?" And they said, "What? That can't be right!"

And then she said, "Raise your hand if you know someone who accidentally killed themselves with a gun," and a couple of hands go up; "Raise your hand if you know someone who killed themselves with a gun in a suicide" — and every hand goes up, because they're all these old White guys, and that's who's the biggest risk for suicide.

Then she said, could we work on this, to try to do something, maybe have a module that you might use, because how many people here are talking about suicide? Nobody. And they said, "Alright, let's work together." And they work together, and they create this module. And they love it — they think it's the best thing.

UD: You're a scientist, you talk about these datasets and policy based on evidence. So, is it working? You've given some very positive examples, but I wonder if the issue is just that when we turn on the TV, the news is terrible.

DH: No, things have gotten worse in the United States. More people are carrying guns, there's more military weapons out there, gun ownership rates have increased a little bit. A lot of bad things are happening. Politically, it's been very hard because one of our two parties is aligned with the gun lobby. So it's hard. But what I would say, from a public health standpoint, is that there's a lot of good things happening, but also, that there's been so many successes in public health over the last 150 years.

From the sanitation revolution in the 1800s, to immunizations, to the United States reducing smoking, you name it — there are so many good things. But all of these things took a long time. Even getting physicians to wash their hands took about 20 years before they would do that.

But people who believe in public health have pushed and pushed and pushed until suddenly things tip. It's three steps forward, two steps back, but it's always been, overall, this incredible movement toward having richer, happier lives.

If you or someone you know are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741.

This article was originally published on Undark. Read the original article.

By Dan Falk


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Gun Violence Public Health Science Undark