Crozet Annals of Medicine: Who’ll Stop the Rain?

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As a physician I have seen the effects that bullets have on human bodies up close. I have studied the science of the effects of bullets on human bodies. I have at my fingertips vast research on mitigating the effects of bullets on human bodies. Over the years we doctors have accumulated great knowledge of how to treat gunshot wounds and by diligently studying the problem we have had success in improving the survival of human beings shot by other human beings.

What I don’t know is how to prevent the uniquely American public health problem of massive gun violence. I don’t know how to do this because, for the most part, the U.S. research establishment has been forbidden by the federal government from studying gun violence. It wasn’t always this way.

In 1993 Art Kellerman, an emergency medicine physician, and his colleagues published an article in the New England Journal of Medicine titled, “Gun ownership as a risk factor for homicide in the home.” The study was funded by the Centers for Disease Control and Prevention. Dr. Kellerman is also an epidemiologist and professor of public health, and he approached the topic as a public health issue that could be understood and solved using the CDCs methods of information gathering and analysis.

The study found that having a handgun in a home increased the risk of homicide in that home by 270 percent. They found no protective effect to having a gun in the home. Most of the homicides were perpetrated by family members or intimate acquaintances.

This study was a widely disseminated and discussed and provoked a backlash by the NRA, which campaigned to eliminate the CDC’s National Center for Injury Prevention, which had funded the study.

As a result of this campaign, the 1996 budget act included the infamous “Dickey Amendment,” named after then-Representative Jay Dickey (R-AR). The Dickey Amendment, which survives to this day, states that none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control. And that was that. Since 1996 the CDC’s funding for firearm injury prevention has fallen 96 percent and is now just $100,000 of the agency’s $5.6 billion budget.

Compare that to the success of the public health model used to tackle the epidemic of highway fatalities.

In 1966 the House passed the Highway Safety Act of by a vote of 318-3, despite opposition by the auto industry. I guess there was more bipartisanship back then. In signing the measure into law, President Lyndon B. Johnson noted that, over the years, more than 1.5 million of “our fellow citizens have died on our streets and highways—nearly three times as many Americans as we have lost in all our wars.”

“Safety is no luxury item,” the president added, “no optional extra; it must be a normal cost of doing business.”

The first director of what ultimately became the National Highway Traffic Safety Administration (NHTSA) under this act, William Haddon MD, was also an epidemiologist and he proposed looking at highway fatalities as a preventable illness. He defined interactions between the host (humans), the agent of injury (motor vehicles), and various environmental (the highway) factors before, during, and after crashes resulting in injuries. Tackling problems identified with each factor during each phase of the crash, NHTSA initiated a public health campaign to prevent motor-vehicle-related injuries.

As a result, changes in both vehicle and highway design followed this campaign.

Vehicles (the agents of injury) were built with new safety features, including seat belts, then shoulder belts, head rests, energy-absorbing steering wheels, shatter-resistant windshields, airbags, antilock brakes and electronic stability control. Each of these interventions was tested in crash test labs and in use and found to save lives.

Roads (the environment of injury) were improved by better delineation of curves (edge and center line stripes and reflectors), use of breakaway sign and utility poles, improved illumination, addition of barriers separating oncoming traffic lanes, rumble strips, and better guardrails. These interventions were studied and found to decrease injuries and deaths.

Host (Drivers) factors were also modified with stricter DUI laws and enforcement, seat belt and child safety seat laws and enforcement and graduated licensing for younger age drivers.

The results have been dramatic and something we now take for granted as a good idea, despite their costs and limits on personal freedoms.

In 1966 there were 50,894 traffic fatalities, a per capita rate of 26 traffic fatalities per 100,000 population. In 2015, with a much larger population driving many more miles, there were 35,092 traffic fatalities, or, on a per capita basis, 11 traffic fatalities per 100,000 population. In terms of fatalities per vehicle miles traveled (VMT), the improvement has been even more dramatic, down from 5.5 fatalities per 100 million VMT in 1966 to 1 fatality per 100 million VMT in 2015.

So I guess I do know how to stop the epidemic of gun violence. As with highway fatalities, we need to look at gun deaths as preventable illnesses. We need to study them, using the tools we have at the CDC and the National Institutes of Health that have been so successful in other epidemic diseases. Clearly from the events of this week, not funding study of the problem is not working.

 

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