Health Care

Guns kill about 90 people a day. Is that a public health threat?

The Marjory Stoneman Douglas High School shooting on Feb. 14, 2018, accounted for less than half of all the gun deaths reported in America that day, according to the New England Journal of Medicine, which notes that about 33,000 people a year die from firearms. But gun deaths are not studied as a public health threat, reducing the ability of doctors and policy makers to develop effective interventions to prevent future mass shootings, say physicians and public health experts.
The Marjory Stoneman Douglas High School shooting on Feb. 14, 2018, accounted for less than half of all the gun deaths reported in America that day, according to the New England Journal of Medicine, which notes that about 33,000 people a year die from firearms. But gun deaths are not studied as a public health threat, reducing the ability of doctors and policy makers to develop effective interventions to prevent future mass shootings, say physicians and public health experts. Bloomberg

On the same day that a troubled former student walked onto the campus of Marjory Stoneman Douglas High School in Parkland and murdered 17 people with an assault-style rifle, at least 28 more people died from gunshots elsewhere in the United States.

Some of those gun deaths were matters of self defense or public safety. Some were suicides, which account for nearly two-thirds of all firearm deaths in America, according to the Centers for Disease Control and Prevention.

But even though doctors and public health officials have long considered gun deaths a public health threat — firearms kill as many Americans each year as die in car accidents — the CDC and state agencies responsible for reducing preventable deaths can do little when it comes to guns.

The CDC used to support studies into gun deaths. But that stopped about 20 years ago, after Congress explicitly said no agency funds could be spent on promoting or advocating gun control — a prohibition that had a chilling effect, experts say, as other funders and researchers backed off.

Except for a firearm safety and fact sheet posted on the agency’s website, the Florida Department of Health does not offer prevention strategies for gun deaths or mass shootings. Even after the Parkland school massacre, the agency was relegated to issuing a call for blood donations and activating the state’s emergency mortuary operations.

The agency monitors Florida gun deaths — and is unable to do anything to prevent them.

“We don’t study these events,” said Lillian Rivera, director of the state health department in Miami-Dade. “Not doing the work of research on gun violence and prevention strategies has taken a toll, and you’re seeing the results as we speak.”

Charles A. Morris, a physician at Boston’s Brigham and Women’s Hospital who co-authored an article about the Parkland shooting and other gun deaths published this week in the New England Journal of Medicine, said that public health officials might be able to make a dent, but they don’t get the chance because the subject is too political.

He said public health officials could learn a lot about why mass shootings happen and how best to prevent them if they were able to study gun violence the way they investigate new infectious diseases, such as Zika by identifying the determinants, understanding the mechanisms and testing interventions.

“Zika is a perfect example,” he said. “People approached it with a sense of urgency, concern and inquiry.”

After the Parkland school massacre, though, the response followed a familiar pattern: intense public attention, funerals attended by thousands, visits from the president and other dignitaries, and a flood of law enforcement resources.

Most of that was focused on who caused the shooting, Morris said, and not why it happened. The reasons may be many, he said, and they won’t be easy to figure out, although he noted that some clues indicate the shooter may have struggled with mental health.

But there’s always a third rail when studying or debating mass shootings.

“Guns are political,” he said. “There’s a reticence to view gun violence through a public health lens, and that’s because Second Amendment issues tend to trump everything.”

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On display at a gun shop in Wendell, N.C., is an AR-15 assault rifle manufactured by Core15 Rifle Systems, on Dec. 18, 2012. Chuck Liddy Raleigh News & Observer/TNS

Florida has averaged one mass shooting per year since 2016, when a gunman killed 49 people and wounded 58 others at the Pulse nightclub in Orlando. The following year, a gunman killed five people and wounded six — with dozens more injured in the ensuing chaos — at Fort Lauderdale-Hollywood International Airport.

Each year leading up to the Orlando massacre, Florida’s firearm death rate had climbed steadily, from 11.5 per 100,000 Floridians in 2014 to 12.6 per 100,000 in 2016, according to the most recent data available from the CDC.

The Florida Department of Health reports that firearms have ranked among the top three leading causes of death for Floridians between 10 and 34 years old in 2013, 2014 and 2015, the most recent dates for which the agency has published the data.

That looks a lot like an epidemic to Roderick King, a physician and associate dean of public health education for the University of Miami Miller School of Medicine.

“There’s many of us who have been pushing on this issue, looking at gun violence and mass shootings as an epidemic,” he said. “Typically when you look at homicides related to guns, it’s usually framed as a criminal justice issue or gun suicides as a mental health issue. Once it becomes a criminal justice issue, it’s no longer a healthcare or public health issue.”

The state health department does not study gun deaths and mass shootings because the CDC, which Rivera said funds the lion’s share of the state’s public health efforts, is limited by a 1996 provision that prohibits the federal agency from collecting data for gun control.

“The CDC is like the mother ship for public health, nationally,” Rivera said. “And if they’re cut [off] at the feet and no leadership comes out of there, you’re going to see very little.”

And though Health and Human Services Secretary Alex Azar said the CDC will research mass shootings such as the Parkland school massacre, Rivera is skeptical the federal agency will fund studies on gun violence, its root causes and prevention strategies.

“You won’t get funding for any of it,” Rivera said.

Rivera said Florida’s health department in Miami-Dade recently allocated about $37,500 in federal and state dollars to study why some babies born to mothers with HIV still contract the virus at birth — a new addition to the agency’s long-running research on fetal infant mortality.

“So why can’t we do it with these gun episodes and find out what’s the root causes of what happened with this child? What were the downfalls?” Rivera said.

King of the University of Miami said the way politicians and civic leaders frame the debate can have a profound effect on the community’s approach to solving the problem of mass shootings.

“We don’t frame it to allow a much more comprehensive interdisciplinary approach, and that’s what public health is about,” he said.

A public health approach to motor vehicle deaths, he said, helped bring about new safety measures, such as mandatory seat belt laws, air bags, retractable steering wheels and other automobile safety features.

The changes took decades to take root, he noted — beginning with science, followed by new prevention strategies, then policies and ultimately social acceptance. But debates about gun violence, King said, are often clouded by a focus on the shooter and systemic failures.

“A lot of the attention is on the shooter, and his mental health, and his family’s situation, and how he interacted with the school. So everything is on him,” King said of the alleged Parkland school shooter, Nikolas Cruz.

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Nikolas Cruz appears in court for a status hearing before Broward Circuit Judge Elizabeth Scherer on Monday, Feb. 19, 2018. Cruz is facing 17 charges of premeditated murder in the mass shooting at Marjory Stoneman Douglas High School in Parkland. Mike Stocker Sun Sentinel

As the FBI, Broward Sheriff’s Office, school officials and others reveal that they missed signs and failed to follow up on tips about Cruz, King said, the debate drifts away from public health and new prevention strategies.

“The minute you ask what caused it, you have to go further upstream,” he said. “What did this kid get access to, and how did he get access to that? What about his life allowed him to develop certain mental health issues and no one picked it up?”

A lot of policy makers and other leaders don’t want to have that debate, King said.

“They want to keep it limited, to focus on people having the right to own a gun,” he said. “The more narrow you keep it, the less accountability there is for the broader community.”

But physicians who deal with gunshot trauma say that has to change.

Tanya Zakrison, a surgeon at Jackson Memorial Hospital’s Ryder Trauma Center in Miami, said she has grown tired of operating on children with gunshot wounds on a near daily basis.

Zakrison estimates that Ryder sees about 600 shooting victims each year. “It’s an extremely unusual day that goes by where we do not see someone who’s been shot,” she said.

Unable to find federal funding for research into gun violence in Miami-Dade, though, Zakrison said she spent her own money to pay for a 2016 study of the social and demographic indicators of shootings in Miami-Dade.

Among the long-term trends Zakrison has noticed, she said, “is that gun violence has gone up since the year 2000. … They’re dying at a higher rate from guns than they are from motor vehicle collisions or influenza or anything that might make headlines in the media.”

But because most firearm deaths involve fewer victims than a mass shooting, and because many occur in Miami’s low-income neighborhoods, Zakrison said, gun violence can be overlooked as a shared public health threat.

“About 13 percent of our patient population who comes in shot will die,” she said. “That’s like five Marjory Stoneman Douglas shootings that occur every year, and has been occurring for 20 years now.”

Daniel Chang: 305-376-2012, @dchangmiami

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