The Public Health Approach to Reducing Firearm Injury and Violence

Firearm injuries are a major public health problem in the United States. The U.S. rates of death and injuries due to firearms, and the rate of crimes committed with firearms, are far higher than those in any other high-income country. In the mid-1990s, rates of property crime and violent crime were comparable in Australia, Canada, New Zealand, and the USA; by 2000, the United States had somewhat lower rates of crime and violence. But what really distinguishes the United States from these countries is its high rate of lethal violence, most of which involves guns. Our firearm murder rate is about ten times higher than the average of these three other countries, and our overall murder rate is three times higher. Canada, Australia and New Zealand all have many guns, though not nearly as many handguns as the United States. The key difference is that these countries do a much better job of keeping guns out of the wrong hands. Like other high-income countries, they have much stronger firearm regulations than the United States. One criterion by which a country may be judged is how it protects its children. By that criterion the United States is doing extremely poorly with regard to firearms. One could pick various groups (e.g., women, youth, the elderly) to examine in detail, but here let us focus on children aged 5-14 - where it is particularly difficult to "blame the victim." A comparison of violent deaths of 5-14 year olds between the United States and the twenty-six other high-income countries in the 1990s shows that the United States had about seventeen times the firearm homicide rate (and a somewhat higher non-firearm homicide rate), and ten times the firearm suicide rate (and the same non-firearm suicide rate) as these other countries. Our unintentional firearm death rate was nine times higher. Through most of the twentieth century, gun assaults were seen almost exclusively as a criminal justice problem, gun suicides as a mental health problem, and unintentional gunshot wounds as a safety issue. Since the mid-1980s, it has become increasingly recognized that the most promising approach to reduce firearm injury is to emphasize prevention. The proactive, community-oriented approach of public health can be contrasted to the often reactive, individual focus of therapeutic medicine and traditional criminal justice. Medicine's principal focus is on curing the individual patient. Medical care providers across the country treat gunshot victims and their families on a daily basis, usually in humane and often heroic ways, but they do so one patient at a time. Similarly, the law enforcement and criminal justice systems seek to apprehend and punish those committing crimes, one perpetrator at a time. Although deterrence is an important goal of the criminal justice and tort systems, and prevention is increasingly seen as a police function, most of the activity still takes place after the fact. By contrast, the goal of public health is neither to determine fault nor to punish perpetrators. Public health focuses directly on prevention - eliminating the problem before something bad happens. Many lessons for effective firearms policies can be learned from considering the public health approach to reducing the negative health effects of tobacco, alcohol, and motor vehicles, while maintaining the free right of Americans to buy, own, and use these goods responsibly. From 1920 through the 1950s, the traffic safety establishment, dominated by the automobile industry, perpetuated the belief that drivers were responsible for accidents. Drivers were suspect, while the actions of engineers and automakers were unquestioned. Proposed remedies focused on eliminating driver fault. Federal policy reflected twin goals: punish the careless driver and instill good driving habits in the general population. The typical question in the 1940s was who caused the accident. It was not until the late 1940s and early 1950s that public health physicians and others began investigating the somewhat different question of what caused the injury. The key to reducing motor vehicle injuries in the second half of the twentieth century reflected a change in approach. It has always been true that most traffic crashes could be eliminated if drivers stopped making errors, and that most traffic deaths could be eliminated if drivers stopped behaving illegally (e.g., speeding, running red lights, or driving drunk). Nonetheless, rather than focusing almost entirely on educating the driver and punishing misconduct, injury-control experts recognized that there were better ways to reduce the likelihood of collision and injury - by improving the vehicle and the highway environment. The automobile industry from the 1920s to the 1960s used the gun lobby mantra, arguing in effect that motor vehicles don't kill people - people kill people. And like many gun advocates today, motor vehicle manufacturers argued exclusively for better education of motorists and increased punishment for bad drivers. By contrast, public health practitioners know that the effort to find fault and place blame is often counterproductive, that the most effective approach to safety is a multi-faceted one, and that often the most cost-effective interventions are those that improve the product and the environment. A second lesson for firearms safety is the important role played by physicians in reducing the toll of motor vehicle injuries. Like motor vehicle safety, firearm safety should be a concern for physicians and public health officials. A third lesson is that success in the motor vehicle area has largely resulted from the availability of good data, which enabled scientists to determine the key factors that affect the traffic fatality rate, and to determine which policies proved effective. A fourth lesson is that it has been the combination of scores of policies and actions that have reduced motor vehicle fatalities; no one single policy, such as seat belt laws or collapsible steering columns, has made the key difference. A final and crucial lesson has been the importance of a regulatory authority with some power over the industry. Like firearms, motor vehicles are constantly changing, and continual oversight is necessary to protect the public health. The public health approach, so successful in reducing the burden of infectious disease and motor vehicle injuries, can also be used to reduce gun violence. The public health approach is scientific, emphasizes prevention, focuses on the community as a whole, and encourages multi-disciplinary and multi-faceted research and action. While gun advocates focus on education and punishment, the public health approach emphasizes that it is rarely cost-effective to direct policy exclusively or even largely toward the individual product user. Good policy also needs to focus on the manufacture and distribution of the product and the environment of the product user. It is unrealistic to expect every individual to behave appropriately and responsibly on every occasion. To prevent injuries, it is more effective to build a system that makes it easier for people to act properly, more difficult to make errors, and less likely for serious injury to occur when people behave improperly, inappropriately, or illegally. People should be held accountable for their actions. Such responsibility pertains not only to the behavior of gun users, but also the conduct of gun owners, gun carriers, gun manufacturers, gun distributors, public officials, and other decision-makers. However, the goal of public health is not to find fault. The goal is to prevent rather than to punish - except to the extent that punishment helps deter and diminish wrongful and criminal action. The public health approach has already broadened the discussions of firearms policy from an exclusively criminal justice orientation to one concerned with all firearm injuries - including suicides and unintentional gun deaths. The entry of public health practitioners into the field of firearm injury control has brought new data sources, new types of statistical analyses, new research designs, and new organizations. It has also brought an increased spirit of science, pragmatism, and optimism.