In the mid-1800s, cholera outbreaks were common in much of Europe. They tended to occur in poor neighborhoods. As a result, many people assumed poverty was a cause; specifically, that the indifference of the poor to hygiene and the associated dirty and crowded conditions created a miasma, or atmosphere, that produced disease. In 1854, John Snow, who is now considered the founder of epidemiology, proved that cholera in fact came from contaminated water. (It wasn’t until the subsequent work of Louis Pasteur and Edward Koch, leading to the germ theory of disease, that the specific cause was determined to be bacteria in the water.) Water treatment then led to the eradication of cholera in developed countries.
In the late 20th century, when a mysterious immune deficiency arose in certain high-risk populations such as gay men and IV drug users, some people also postulated that it was caused by their lifestyle. Of course, the discovery of the HIV virus debunked this notion. Appropriate preventive measures again led to sharp decreases in the spread of AIDS. Cholera, tuberculosis, HIV – these and many other infectious diseases which were previously attributed to moral factors are now recognized as public health issues. Trying to eliminate such ailments by proselytizing among the poor or “curing” homosexuality would be foolhardy at best. Rather, they have been addressed successfully through public health interventions such as water treatment, immunization, and risk education. What were once the most common causes of death in children have been nearly eliminated in the developed world.
Unfortunately, a new scourge has arisen to fill that void, at least in the US. From 2000 to 2016, almost 49,000 children 0-19 years died from firearm injuries. (No, that is not a typo.) That is 2868 boys and girls every year, 8 per day, one every 3 hours. They are shot at home, at school, on the playground. Firearms are one of the leading causes of death in childhood, accounting for 3% of all deaths ages 1-9, 9% of all deaths in children age 10-14, and an astonishing 21% of deaths in 15-19 year olds. Some of these are accidental, but in the 10-14 year olds half are intentional and one-third self inflicted, while almost half the deaths in the teens are suicide. (Note that guns are not the most common method of self-harm in youth, just the most lethal.)
As with cholera and HIV, there are those who argue that this is a moral issue: guns don’t kill people, bad people kill people. Or at best it’s a mental health issue. But it’s not, and least not primarily. It’s a public health issue. And only public health methods will be successful in controlling it. There are 3 main elements: surveillance, mitigating risk factors, and promoting protective factors.
Now, my gun theory of disease states that guns are the primary cause of gun injury. That should be obvious. But just as with the germ theory, that doesn’t necessarily translate into eliminating all guns. After all, our bodies are filled with good germs. We just need to take steps to understand how to keep guns from causing harm.
First, surveillance. Successfully combatting firearm injuries in children requires much more data on the risk and protective factors, which means more research. The Dickey amendment, promoted by the NRA and part of federal budgets since 1996, prohibits the use of federal money for research that could be used to advocate for gun control. As a result, federal support for firearm research has been negligible; just this year, the NIH awarded its first grant for pediatric gun research.
Second, we know some of the risk factors for firearm injury. Mental illness is certainly one. So is weapon design. The AR-15 is the HIV of guns, incredibly lethal. Finally, we know some things that can protect against injury. Smart technology that prevents firing by anyone other than the owner, or accidental firing, is a highly promising approach to reducing the risk of injury. Safe storage is another: keeping guns unloaded and locked up greatly decreases the risk of both accidental and intentional injury in children. Yet an incredible 4.5 million children live in homes where guns are stored loaded and unlocked. Parents need to know the one question that can save their child’s life: is there an unlocked gun where my child plays?
It is possible to have society where guns are legal yet safe. Finland and Canada are 2 countries with similar levels of gun ownership as the US, but death rates around one-quarter of ours. It will take both legislation and education, both key pillars of successful public health strategies. And those of us who advocate for kids need to help with both. (Dr. Sheldon Berkowitz wrote a nice column on this in the November MN AAP newsletter.) 84% of pediatricians surveyed agreed that gun injury is a public health issue. Yet only around half thought it was their role to discuss or counsel families about guns. That is absurd. It’s like saying it’s not our role to give vaccines, or discuss smoking at home. That’s what the NRA thinks, too. They recently tweeted that with regard to gun issues, physicians should “stay in their lane.” Well excuse me, Mr. LaPierre, but when it comes to public health, physicians have the whole damn road.
In a country where there are more gun stores (64,417) than bookstores (23,753) and grocery stores (38,571) combined, there is much work to do. But anyone who was around in the 1980s can recall the sense of doom about HIV. Germs can be tamed. So can guns.