Violence is a Public Health Problem

Dorothy Guellec

According to the FBI there are 240 million firearms in America today. Former U.S. Surgeon General C. Everett Koop identified violence as a public health issue in 1991. The Centers for Disease Control tells us "the United States may be a more violent society than all other industrialized countries." Examining violence in the context of public health was a relatively new idea and started appearing in the literature in the 1970's with articles in medical and public health journals on homicide, gunshot wounds, firearms accidents, etc. Nowhere is the peculiarly American ambivalence toward violence more evident than in the issue of guns. From 1968-1994 firearms related deaths increased by more than 60%.

Violence is a threat to a community's health and social order. Medical and Public Health personnel are in unique positions where they can see violence that is not reported to authorities. Physicians are directly affected by firearm injuries. In a recent survey 87.7% reported that they personally had treated or knew someone who had been injured in a gun accident. (Annals of Internal Medicine)

Violence around the world takes different forms. In India, Pakistan, Bangladesh and Sri Lanka there are honor killings, dowry deaths and female infanticide. In Africa civil wars rage with devastating consequences to both men and women, not to speak of AIDS and female ritual castration. In times of war women are more likely to suffer rape and other human rights violations. At the end of 1999, 56 of the 188 UN member states were involved in violent conflicts, resulting in 35 million refugees and internally displaced people, mostly women and children. Sexual violence is a strategy in war. Widespread rape has been documented in the former Yugoslavia, Rwanda, Bangladesh, Uganda, Burma and Somalia. It is a highly effective means of terrorizing entire communities: because of the emphasis most cultures place on the sexual virtue of women, the rapist is able to humiliate demoralize.

Those who support capitalism in one form or another dominate contemporary American thinking about policy issues. There has been very little written about the political economy of a capitalist society in the creation of violence. While liberal rhetoric "focuses on the need for major social reforms to combat crime, liberal policies rarely go beyond social tinkering."

Most of the public, social scientists, and politicians subscribe to the dominant (i.e. contemporary American capitalist) ideology of crime, which assumes it is possible to create an effective and humanitarian system of crime control under the present economic and political framework. Actually these ever-increasing elite bodies never think of what policies would be truly humanitarian. They focus rather on the status quo (capitalism) as the best of all worlds and believe that the crime problem can be solved by quick, sure punishment, individual change, plus a return to conservative and religious values.

That being said, what is the contemporary landscape? By the year 2003, gunfire will have surpassed automobile accidents as the leading cause of traumatic death in the U.S. (JAMA 1996). More U.S. teenagers die from gunshot wounds than from all natural causes combined. Firearms are involved in 65% of suicides among persons under the age of 25. Suicides among children have been increasing, and the acquisition of guns makes suicide attempts more successful. For every death involving firearms, twice as many persons with firearm-related injuries need hospitalization and five times as many need outpatient care. Firearms in the home pose more of a threat to members of the household than to intruders. Having a firearm in the home increases the risk for death by suicide fivefold. The risk for death by homicide is three times greater.

Gun violence isn't the only form of trouble that has made the transition from nonmedical cause to medical issue. Alcoholism, narcotic abuse, domestic violence, and tobacco use were all once considered the province of the courts, the church, or society at large, not medicine. All have been reframed, and rightly so, in medical and public health terms. Alcoholism is now considered substantially a medical problem - an actual disease - with the usual genetic, biological, chemical, and social dimensions. Why this model has not spread to drugs is still a very complicated story involving money, greed, and the economies of many countries. The U.S. is the ringleader. If William F. Buckley favors legalizing drugs why do so many others object. Obviously there are no clear answers.

Reframing gun violence as a medical concern seems, for the time being, to make good sense, because the public dialogue can be changed radically. This is why a number of doctors have begun to think of gun violence as a public health issue. Have they thought about it in a meaningful way? Medical schools and the clinicians they produce have "never been very receptive to the public health perspective." Even if most internists and surgeons are already convinced that firearms are a medical and public health problem, most have not yet managed to make the leap from belief to practice.

Progress toward understanding a problem as complex and elusive as violence has been slow. "At the end of the 20th century, we are as close to understanding violence as we were to understanding medicine in the mid-1800s," observed Felton Earls director of the Project on Human Development in Chicago Neighborhoods. This project will track 6,000 children in 80 Chicago neighborhoods until 2003 in an attempt to identify factors that risk violent behaviors. The study encompasses African-American, Latino, white and mixed ethnic neighborhoods, and all social classes. "By a detailed study of Chicago, we sample the whole universe of urban America," he says.

Another Doctor, Deborah Prothrow-Smith has crusaded to bring violence prevention within the rubric of public health. Her 1991 book "Deadly Consequences" combines anecdote and analysis to support the public health approach to violence. In her book there is no coverage of state or corporate crime. Smoking is seen as a public health problem but there is no blame heaped on the tobacco industry or the government. One chapter is devoted to the corrupting effects of the media and handguns are viewed as contributing to the crime problem. There are concerns about drugs, poverty, and the underclass, but there are no proposals of a radical nature to deal with them. She does not answer those who suggest that violent urges lie in the genes and are not amenable to social programs or medical intervention.

"Day after day, 100 people die from guns-and half of these are suicides. Clearly it's an American problem. Almost no other countries allow handguns for personal enjoyment," observes David Hemenway, deputy Director of the Injury Prevention Center and Professor in the Department of Health Policy and Management. He points out that there has been relatively little research on guns given their public health importance. Accordingly, he has become something of a one-man firearms think tank investigating everything from who owns what to who belongs to the National Rifle Organization.

He found, for example, that men are more likely town guns than women. Republicans are more likely to be armed than Democrats - common sense to me. But contrary to common sense gun owners who have had firearms training are more likely than others to be among the 1 in 5 who store guns loaded and unlocked. Maybe they are just more into it. "It seems that training is associated with poor storage habits." Hemingway's studies suggest that training in conflict resolution and open family discussions may protect children from catching the handgun "bug." Is this just a band-aid solution? Maybe the law and order approach is not the way to go; rather money should be shifted from the war on crime to solving social problems. "As a society we tend to look at social ills piecemeal with a focus on cosmetically fixing the apparent result without correcting the root causes of the problem." If violence is a health issue, then its prevention will be pursued honestly when major medical journals begin to publish articles that cite capitalism, racism, and sexism as causes.

Doctors Against Handgun Injury is a new organization with a broad base of 13 clinical and medical societies in its membership. This group will soon try to lobby for greater data collection among other things. They hope to track the behavioral aspect of patients by asking detailed questions in hospital, ER and out patient centers. I cannot criticize these efforts but they seem a little tame.

There is very little in the literature about the Second Amendment and gun control from Public Health advocates. The rationale heard most often among supporters of gun ownership is that the Second Amendment gives the individual a right to own a weapon. Ancestor worship among the political elite still flourishes, and we as a nation pay homage to the wisdom of the "Founding Fathers." These people believe in strict interpretation of the Constitution. This is their true goal to recover its "original meaning" or the "original intentions" of its adopters. "Originalism, as it is called, assumes that a fixed set of meanings was locked into the Constitution at the moment of its adoption, and that these meanings enjoy a supreme legal authority that should guide and constrain the course of interpretation." In my opinion this is absurd. We do not have the same country we did in 1787 and in many ways our Constitution and our so-called Republic are "frozen". Nothing in the Constitution literally directs us to prefer its original meaning over all other modes of interpretation.

Violence in all forms 1) weapons 2) media images 3) insensitivity towards human life 4) the degrading way women are treated all over the world, etc is growing and has reached epidemic proportions. I personally do not agree with Ivan Illich and his raging against the medicalization of much of human activity. What bothers this 20th century Rousseau is that "medicalization destroys the natural ability of individual persons to cope with adversity and to heal themselves." Medicalization, he asserts, "deadens people's native sans culottes wisdom, infantalizes them, and suppresses their autonomy, and erodes support by their community." This is too sweeping and somewhat naïve.

Dorothy Guellec guellec@purvid.purchase.edu