Yesterday, the Supreme Court heard District of Columbia v. Heller, which pits DC’s handgun ban against the Second Amendment. DC’s gun law is the strictest in the nation, since it effectively all handguns; it does, however, allow for rifles and shotguns if they’re kept disassembled or under trigger lock. The big issue is whether the Second Amendment – “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed” – guarantees an individual right to gun ownership, or only a collective right that hinges on militia service.

For the public health community, the question isn’t what the framers intended, but what works.

First, a look at the problem: In the United States on average, 81 people die from gunfire every day. Medical care for firearm injuries runs an estimated $2 billion each year, and because so many gun violence victims are uninsured, taxpayers shoulder much of the medical cost – 85%, according to one study. It’s harder to find numbers for the grieving family members left behind, or the people who are afraid to venture outside or sleep next to an exterior wall for fear of being hit by a bullet, but we know gun violence also takes a substantial toll on mental health.

So, do gun bans help reduce the toll of gun violence? From 2000 – 2002, the Task Force on Community Preventive Services reviewed 51 scientific studies on the effectiveness of firearms laws in preventing violence, and published their results in MMWR. Their conclusion:

The Task Force found insufficient evidence to determine the effectiveness of any of the firearms laws or combinations of laws reviewed on violent outcomes.

They went on to note that “insufficient evidence to determine effectiveness should not be interpreted as evidence of ineffectiveness” – in other words, absence of evidence is not evidence of absence.

The Task Force looked at two studies that specifically addressed DC’s handgun ban, and reported that the two studies came to different conclusions; the Task Force also found inconsistent results from four studies on the effects of registration and licensing and three on child access prevention laws. The authors pointed out several recurring problems with studies evaluating the effects of firearms laws on violent outcomes: evaluations haven’t accounted for the degree of implementation of laws; crime data are substantially under-reported, and often aggregated; study designs and analytic techniques are often problematic; and measuring potential confounders is challenging. We obviously need more studies on the effectiveness of gun bans, but these problems will be hard to solve.

Lessons from Motor Vehicles, Tobacco, and Alcohol
In a 2001 Journal of Public Health Policy article, David Hemenway calls for a firearm policy approach modeled after that of motor vehicles, tobacco, and alcohol, noting several similarities between the four products:

For all four products, the goal has not been to prohibit manufacture or ban consumption but to minimize the burden on the public’s health. For all four products, many of the harmful results are imposed on others. And for all four products there are strong and opposing commercial and vested interests whose main concern is not the public’s health, but increasing the sales and the general acceptance of the product. … The affected industries have tried to focus policy efforts exclusively on education and enforcement, and have typically portrayed any product-related problems as caused by a few blame-worthy users.

Hemenway describes how research has helped overcome the industry narratives. Auto manufacturers blamed drivers for the accidents that caused so much death and injury, but researchers linked vehicle design features to common crash injuries (shifting the emphasis from the cause of the accident to the cause of the injuries); today we can thank auto safety features like seatbelts and airbags for reducing the rate of death from motor vehicle accidents. Tobacco companies argued that smoking is a personal choice, but researchers provided evidence of the harmful effects of secondhand smoke, and restrictions on smoking in public spaces followed. Alcohol companies argued that the vast majority of drinking was perfectly harmless, but World Health Organization-sponsored groups of researchers demonstrated that the more alcohol is restricted (through taxes, age restrictions, etc.), the lower the rates of cirrhosis, highway fatalities, and other alcohol-related problems are. Restrictions on when, where, and how much alcohol can be sold (and for what kind of price) are now more common than they used to be, and drunk-driving deaths are down.

The article points to several lessons that firearm-control advocates can learn from these successes:

From motor vehicle policy, to remember that
• blaming individual users is counterproductive;
• physicians can play an important role; and
• having good data from a comprehensive surveillance system is crucial.

From tobacco policy, understand the importance of
• independent federal data analyses, investigations, and reports on the product’s danger;
• “the costs imposed on innocents”;
• the product’s symbolism in the media and culture as a whole;
• grassroots activism; and
• tort law.

From alcohol policy, to focus on
• restricting who can use the products and where they can use them;
• the costs that the products’ use imposes on innocent victims;
• federal funding for research; and
• debunking the dichotomous depiction of the world as having “a small percentage of problem users and everyone else.”

From the Gun Lobby, a Different Kind of Prevention
Perhaps the gun industry has also learned from the examples Hemenway cites, because it has lobbied successfully to cut off some of these avenues, or at least block them for a while. Hemenway, after citing the importance of comprehensive surveillance data about motor vehicle fatalities for advancing vehicle-safety interventions, points out that the CDC is planning to develop a National Violent Death Reporting System that will collect comprehensive death information on firearm fatalities – “hoping to resume the role they relinquished in the mid-1990s due to gun lobby-induced cuts in appropriations.”

Information about how crime guns circulate can also be useful in studying gun violence prevention; for instance, the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) traces the origins of guns used in crime, and in 2000 estimated that 57% of crime guns came from 1.2 percent of licensed dealers. The gun lobby evidently didn’t like this kind of research, though, and since 2003, budget riders – often referred to as Tiahrt amendments after Kansas Rep. Todd Tiahrt – have severely limited the gun trace information that local law enforcement agencies can get from ATF.

After Hemenway emphasizes the importance of tort law in tobacco control, he notes that “the gun industry is having success at getting state legislatures to prohibit lawsuits brought against it by local industry.” After this article was published, the gun lobby scored an even bigger coup at the national level, with passage of the “Protection of Lawful Commerce in Arms Act,” which prohibits liability actions against firearms or ammunition manufacturers and sellers for crimes committed with their products.

In “A Public Health Perspective on Gun Violence” (the first chapter in Suing the Gun Industry: A Battle at the Crossroads of Gun Control and Mass Torts) Julie Samia Mair, Stephen Teret, and Shannon Frattaroli bring up another potential public health strategy: regulating firearms as consumer products that should be engineered to prevent their operation by children or anyone else besides their owners. Ordinarily, the Consumer Product Safety Commission is (as its name suggests) responsible for overseeing the safety of consumer products; however, Congress has expressly forbidden the CPSC to regulate gun design safety.

Options for the District
Analysis of yesterday’s oral arguments in the Supreme Court suggests that the Justices will come down on the side of individual gun rights and declare DC’s handgun ban to be unconstitutional. We’ll have to wait until June to see what kind of gun restrictions they decide governments are constitutionally able to make.

No matter what kind of gun laws are eventually allowed, DC needs to do something about gun violence. Although 2007 marked our fourth consecutive year of having fewer than 200 homicides, our rate of 30 homicides for 100,000 people is still higher than New York’s or Chicago’s (Baltimore and Detroit fared worse). Of the 181 homicides in 2007, 77% of the victims were killed by gunfire, and 80% of the victims were black males.

Violence prevention programs are nothing new – it seems like most comprehensive anti-crime proposals call for better school programs and more economic development in high-crime neighborhoods. With most states facing budget shortfalls, though, it can be hard to get (or sustain) funding for such efforts. Two recent studies suggest interventions that can save millions of dollars by reducing crime in later years, and perhaps their emphasis on the numbers will help make the case.

Niko Karvounis at Health Beat has an excellent two-part series, “Healthy Kids, Less Crime,” that starts by describing a study published recently in the American Journal of Psychiatry. Duke University researchers followed a sample of 1,420 children, ranging from 9-13 at the start of the study, for psychiatric disorders annually until age 16, and then ascertained their criminal offense status in young adulthood through court records. They found that childhood psychiatric profiles predicted all levels of criminality, and concluded (footnotes omitted, emphasis added):  

Both male and female participants with childhood psychiatric disorders other than conduct disorder were twice as likely to be involved with the criminal justice system as young adults than those with no childhood disorder, and their criminal activity is far from insignificant, with risk concentrated on the most serious forms of offending. Particular attention should be paid to youths with a history of multiple diagnoses, even if they did not occur simultaneously.

If childhood psychiatric status is, as this study suggests, a common risk factor for criminality, effective treatment of childhood psychiatric disturbance may reduce the subsequent burden on the criminal justice system. Childhood treatment may also be cost-effective: a recent study estimated average annual mental health service costs across seven service sectors at $4,500 to $7,000 for children with diagnosable disorders, whereas the direct costs of adult incarceration are approximately $23,000 a year in federal facilities. Yet less than half of children with multiple psychiatric disorders receive any mental health services.

Then last week the Washington Post reported, based on an Alliance for Excellent Education study, that the District could save $700 million a year in crime-related costs if it could increase the high school graduation rate by 5%. Perhaps the additional $44 million our school chancellor is requesting for art, music, social workers, and activities will seem a bargain by comparison. We still have a lot to learn about what works to increase graduation rates, though.

Looking at the percentages and dollar figures, it can be easy to forget what we’re dealing with. Here’s snapshot, from Allison Klein’s Washington Post article about crime in 2007:

Neighborhood organizers are concerned that the city could be on the threshold of another violent era. Trayon White, a community activist, said he knew five of the year’s homicide victims, including a former classmate, Tiara Merriweather, who was gunned down as she played cards on a summer night not far from White’s house.

Merriweather, 24, a mother of two, was killed June 30 in the 3500 block of Stanton Road SE — an innocent casualty of a drive-by shooting. She was among the 60 people slain in the city’s 7th Police District, up from 44 in 2006.

“Living in the streets, you get numb to it and learn to cope with it,” said White, an outreach worker for East of the River Clergy-Police-Community Partnership, a grass-roots group. “It’s hard for me to cry when I go to funerals anymore.”

Gun violence is a multi-faceted problem, and a powerful gun lobby opposes many of the attempts to address it. But we can’t let ourselves get numb to it and give up.

Liz Borkowski works for the Project on Scientific Knowledge and Public Policy (SKAPP) at George Washington University’s School of Public Health and Health Services. She thanks the professors of her Policy Approaches to Public Health class for teaching her most of what she knows about gun violence.

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