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Let’s Get Behind This Effort To Reduce Gun Violence.

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              Over the weekend, I received a message from our good friend, Shannon Watts, asking me to donate to an organization, Advance Peace, which is working to reduce gun violence. My only regret is that I couldn’t send more money because right now I am scraping together all my dough to give to the DNC for 2022.

              I’m not such a po’ boy that I won’t give Shannon another donation when she asks again, because I always do what Shannon asks me to do.

              Be that as it may, I wanted to spend a bit of time talking about the efforts of Advance Peace and other organizations which refer to themselves as conducting ‘deterrence’ programs to identify people most at risk of being involved with gun violence and offering them pathways that will deter the violence before it occurs.

              Getting down to the street level and working with individuals who are prone to get involved in the endless and continuous cycle of inner-city gun violence has been a strategy led by various groups since the 1990’s, chief among them being Ceasefire, a program that first started in Boston in 1996, and Cure Violence, which came out of Chicago in 2000. Both programs operate in cities across the United States.

              What makes Advance Peace unique in this workspace is the focus not on group deterrence, particularly working with members of gangs, but identifying the most vulnerable individuals, and dealing with them on an intensive, individual level. The targets of this effort are given eighteen-month Peacemaker Fellowships which hopefully will guide these Fellows into productive and non-violent lives.

              The program run by Advance Peace in Sacramento went from July 2018 through December of the following year. For all of 2019, Sacramento registered a 21% decline in gun homicides and gun assaults. As someone who spends part of every day looking at gun-violence data, I can tell you that a 21% decrease in a city the size of Sacramento is a very, very big deal.

              But what about the bottom line? How much are we paying to see this evident reduction in gun violence? The ROI (costs versus benefits) is often cited as a reason such programs are pie-in-the-sky responses which can never be sustained. True or not true?

              You can find a very detailed financial analysis of the Advance Peace Sacramento program on their website. The analysis was done by faculty at Berkeley’s Institute of Urban and Regional Development (IURD), so this report is a no-bullshit deal. And here’s what it says:

  • The Fellows were 98% male, average age of 23 years, 96% African-American, 65% with prior arrest or incarceration, 84% unemployed and 84% victims of a prior gun injury.
  •  By the end of 2019, 64% completed the program, 90% had no new gun charges, 44% had no new arrests, 25% achieved positive life-changing milestones, and 20% were employed.

What did these numbers mean in terms of ROI? By dividing the financial benefits of the program by its costs, for every dollar that was spent on the program, the city of Sacramento did not lose between $18 and $41 in costs that would have occurred had gun violence in the city remained at its pre-program level. These costs included policing, incarceration, medical and unemployment expenses.

So, both in terms of the human and financial results of this effort, we have to say that the Advance Peace program scored well. And let’s not forget that this was one of th4e first two such programs that ran in 2019, the other being a program in Richmond, CA which had comparable results.

Interested in reducing urban violence in a community where you live? You can connect with Advance Peace and begin the process of bringing them to your city right here.

Because I’m Mike the Gun Guy™ and Mike the Gun Guy™ always has to say something a little critical about efforts to reduce gun violence even when he likes a particular effort very much, as is the case with Advance Peace. So here goes.

According to the IURD report, the program staff interrupted and therefore prevented 58 gun assaults by mediating at least 58 conflicts where someone was carrying a gun. In other words, without the presence of Advance Peace in these high-violence neighborhoods, perhaps 58 or more individuals would have been injured or killed. Fine.

But – and it’s a very important but – after these mediations took place, what happened to the gun? The report is silent on that point.

Is it realistic to talk about permanently lowering the violence level in any community or neighborhood when the number of guns floating around in that area stays the same? Cn we realistically pin our hopes for the reduction of community violence if the means of committing that violence doesn’t change?

Don’t get me wrong. The work being done by Advance Peace is important and really does deserve all our support. You can and should send them some dough right here.

Let’s just not forget the other side of the coin which is that gun violence wouldn’t be tearing up inner-city community life without all those guns.

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A Surgeon Talks About Gun Violence.

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The author of this piece is a surgical resident in Pennsylvania and this column, along with her painting (above) was published in the June 10th edition of the New England Journal of Medicine.

To say that the Covid-19 pandemic has changed all our lives dramatically is an understatement. The population of North Philadelphia is no exception. In a city where gun violence was rampant before Covid, bloodshed has only increased with the upheaval of the structure of everyday life. Over the past year, there have been more than 2200 shooting victims and 500 homicides in Philadelphia, reflecting increases of 54% and 40%, respectively, over 2019.1,2 In November 2020, while completing a trauma rotation, I witnessed the aftermath of such violence. One boy, along with many others from that time, will always haunt me.

When he arrived in the trauma bay, he was alive. He had been shot in the chest. I immediately started working to gain access to his femoral vein as another doctor monitored his airway. His legs were kicking as he screamed, “Help me! Help me!” As I focused on securing the central line, I noticed that the nurse holding his legs down no longer needed to apply as much force. His writhing had slowed, then stopped. I looked up at the head of the bed, where the trauma chief and the attending stood, and glanced down just in time to see the light in the patient’s eyes go out. “Don’t leave, don’t die. We’re here,” I pleaded silently.

Everything happened so quickly, like a choreographed dance. The urgency in the room was palpable. Everyone had a role, and all those roles were equally vital to the objective. One resident was intubating the patient. The chief resident took a scalpel to the left chest, just caudal to the nipple, curving cranially as he drove the knife to the bed. He saw me beside him and handed me the scissors. I opened the chest to find blood, as another resident placed a chest tube on the right. Blood sprayed out under pressure. I knew what that meant. I wielded the metal mallet and hammered the bladed bar across the sternum, extending the thoracotomy into a clamshell. We placed the Finochietto retractor, opened the pericardium, and cross-clamped the aorta. Blood was everywhere.

I scooped blood and clots out of his thorax to identify the injuries. And there they were. An 8-cm hole blown through the right atrium and a 10-cm hole in the posterior inferior vena cava. We did our best to clamp the holes and attempt cardiac massage. The clamps were not big enough. They would not hold, as blood leaked around them during attempts to squeeze the heart. We started sewing urgently, in an attempt to stop the bleeding and pump the heart. Even with our best efforts and several transfusions, there was no bringing him back. He had left us. What I saw before me was a teenager covered in his own blood, his chest flayed open in the attempt to save his life. The dance was over, and it had not been fast enough.

The attending called out the time of death. The room had quieted, and the teams shuffled out. I stayed, alone with the shell of a human, left to close the chest that I had opened. I closed his eyes and covered his lower body in a blanket, then began meticulously sewing his chest closed with silk.

When I was finished, I trudged to the locker room to change my scrubs – my pants were soaked in dark blood. I was shaking from the adrenaline crash, and my eyes were swimming with tears. As I pulled off my scrub pants, I realized the blood had seeped through to my skin. A nurse in the locker room looked at my shins in horror and brought me chlorhexidine wipes, a gentler solution than the bleach wipes I was using to scrub away the blood. I knew I had to pull myself back together. I knew my pager could go off any minute for the next trauma. I walked the halls and did what was required of me to finish my 24-hour shift. I felt numb as I walked out to the garage the next morning. I called my sister on the drive home, and I finally let myself fall apart and cry. “I am a surgeon. I am supposed to be able to stop bleeding.”

Over the course of the 6-week rotation, I was involved in seven emergency thoracotomies in patients with gunshot wounds. It was difficult, but over time I found peace in the quiet after each procedure concluded. I gently closed the patients’ empty eyes, covered their bodies, and sutured. Somehow, in making that closure perfect while I thought about their too-short lives and the loved ones they’d left behind, I felt that I was honoring the victims. Looking back now, I think that maybe in choosing to take on the task of approximating the skin of those corpses, I was really trying to put myself back together. I had been changed by what I had seen, and I knew it. I spent time coping outside work by painting a picture of that first boy (see image). I let myself feel the pain again with each stroke of scarlet paint across his body.

I wanted others to know about these violent deaths. I wanted people to know what I had gone through, what I had seen. I wanted them to understand it on a deeper level than the statistics they read in the news reports.

As I attempted to tell the people around me, however, I realized it was too heavy, too painful. It made them uncomfortable. My brother, an Army Ranger, who had recently returned from deployment overseas, pulled me aside. “We signed up for jobs where we see horrific things,” he said, “so that those we love don’t have to see them.”

Later, I was recounting the gory details of my rotation to one of my attendings, explaining how angry and frustrated I was. This was not what I had signed up for, I told him.

“Yes, you did,” he assured me. “You just didn’t know it.”

His response will stay with me, along with the faces of so many patients in their final moments. I am certain that no one can fully prepare for what they will encounter in medicine, nor what the profession will require of them. I certainly did not foresee the coming of a pandemic before starting this career. The reality is that we are often witnesses to the lowest and darkest moments in many of our patients’ lives. Residency takes from us in myriad ways; above all, it demands our time. I now know that it is paramount to set aside time to cope with loss and death — not only for our immediate well-being, but also for our self-preservation. Three years into my career as a surgeon, I am beginning to understand the true gravity of what I signed up for.

The Medical Plan To Reduce Gun Violence That Doesn’t Work.

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              Doctors for America is a liberal advocacy group that was formed in 2008 to help promote the Affordable Care Act and now continues to push for all kinds of goody-goody medical things. One of their goody-goody’s is reducing gun violence for which they have produced a video which depicts a physician talking to a gun owner about how he stores his guns.

              The gun owner is a young married guy with a daughter in the home. The physician asks him where he stores the guns when he’s not hunting, and he claims he puts them on a high shelf which is out of his daughter’s reach. The doctor tells him that what he should really do is lock the guns up because they otherwise there’s a risk of suicide or accidental injury. The guy playing the role of the patient agrees.

              There is not one, single study ever produced which shows any direct connection between safely storing guns and eliminating or even reducing gun violence – not one. The idea that safe storage represents an effective response to gun injuries is an assumption promoted by physicians and medical advocacy groups who actually believe that they can gain the confidence of gun owners by pretending that it’s okay to own a gun.

              It’s not okay. The research by Art Kellerman, Fred Rivara and their colleagues published more than a quarter-century ago clearly proves that access to a gun in the home represents a medical risk, and this research did not qualify those guns in terms of whether they were stored safely or not.

              The Hippocratic Oath requires physicians to identify and then work to reduce medical risks. Simply put: Medical groups which promote the safe storage nonsense are violating the Hippocratic Oath. They get away with this crap because their members and their audiences know as much about guns as they know about guns – zilch.

              Want to see another example of how the medical community is completely and totally divorced from reality when it comes to talking about guns? There’s an organization called UpToDate that publishes an online reference database which physicians can use to read the latest studies on any medical problem, as well as print out simple summaries and advice for patients to read. The website is probably accessed by just ab out every primary-care doctor in the United States.

              Here is how UpToDate describes what it does: “a global community consisting of thousands of physician authors and editors who share a singular passion: writing and editing evidence-based information that helps clinicians everywhere practice the best medicine.”

              So now let’s look at the section on gun violence and, in particular, the handout that physicians can print and give to patients regarding the risk of their guns: Patient education: Gun safety for families (The Basics) – UpToDate. Scroll halfway down the page and you’ll see what UpToDate believes a parent should tell a child in order to teach the kid about gun safety: Do not touch the gun. Move away from the gun. Tell an adult. 

              Now take a look at what the National Rifle Association says is the proper way to teach your child gun safety. You can see it right here: Eddie Eagle | NRA Explore.  Scroll down slightly and guess what you’ll see? You’ll see the exact, same safety message for kids that you’ll see on the UpToDate page.  The NRA has been pushing this nonsense for years but now they have an ally in the medical community to help spread their message around.

              How can any doctor utilize any messaging about guns which was developed by the same organization which got a law passed in Florida that would have criminalized any physician who counseled patients about gun risk? Groups like Doctors for America should be ashamed of themselves for even thinking that there’s some kind of common ground which they can occupy with gun owners to reduce gun risk without getting rid of the guns.

              If any physician would like to explain to me how promoting ‘safe storage’ of guns isn’t a violation of the Hippocratic Oath, I’m all ears.

An Important Reference Work On Gun Violence.

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              I have just finished reading and studying a collection of articles which together constitutes the most important reference work on gun violence which currently exists. The book, Pediatric Firearm Injuries and Fatalities, is a collection of 15 articles edited by Eric Fleegler and Lois Lee, both of whom are pediatric-ER doctors at Boston’s Children’s Hospital, so they’ve seen plenty of gun injuries over the years. You can buy the book here.

              The collection is described as a ‘Clinician’s Guide to Policies and Approaches to Firearm Violence.’ Each contribution is a summary of research on a particular aspect of gun violence, along with copious footnotes and ‘Take Home Points,’ the latter lists some basic strategies that clinicians can use for responding to injuries caused by guns.

              Let’s be clear. This isn’t a collection of original, evidence-based articles. It’s a collection of articles which summarize all of the research which has been done to date on specific aspects of gun violence, in particular gun violence which impacts kids. And don’t make the mistake of thinking that by limiting the contents to pediatrics, that you won’t get an overview of gun-violence issues as a whole. Because pediatrics happens to include everyone up to age twenty-four, and by that age you are looking at a majority of the gun-violence events which occur every year.

              This encyclopedic work is divided into two sections: risks and interventions. The risks are homicides and assaults, accidents, suicides, international comparisons, and school shootings. The interventions cover counseling patients before and after shootings, community-based programs, safety design for guns and legislative advocacies.

              Together, these articles cover just about every aspect of what clinicians need to know in order to develop effective responses to gun violence. Together, the articles cite more than 700 references to evidence-based research which means that this work is not ground in opinion but in facts, a welcome change from the way most gun discussions are framed.

              That being said, as usual I have several issues with specific content in this valuable collection which need to be raised. First and foremost is the degree to which public health gun research continues to focus the research on every issue except what I consider to be the most important issue, namely, how, and why gun violence actually takes place.

              The articles which define gun risk are overwhelmingly based on CDC data which tells us all about the victims of gun violence but nothing about the perpetrators of same. I don’t understand how public health researchers can refer to the ‘epidemiology’ of this particular health threat when little, if any time is spent trying to figure out how and why a certain population uses a gun in what the gun industry would call an ‘inappropriate’ way. After all, shooting someone isn’t the usual way that a dispute between two people is resolved.

              Because we know very little about who actually shoots guns inappropriately, how can we really create effective public policies and clinical procedures for reducing such behaviors? I don’t think, in fact, that we should assume that evidence-based research on gun violence can guide our policy strategies when the evidence tells us little, if anything about the people whose behavior we are trying to change. I should add, by the way, that in 4 of the 5 states which implemented comprehensive background checks after Sandy Hook, gun violence rates went up, not down.

              Finally, I have a big problem with the degree to which the entire gun-control community – physicians, researchers, advocates – invariably propose linking up to every relevant ‘stakeholder’ in the gun violence debate with the exception of the most important stakeholders of all – the companies who manufacture the guns.

              If you believe that companies like Glock or Smith & Wesson aren’t concerned about gun violence and gun safety, this only demonstrates that you haven’t gone into a gun shop and purchased a new gun. Because every gun shipped from a factory to a retailer must have a warning which says that the gun, if misused, could result in injury or death. And the warning is printed in big, red letters, okay?

              I’m not saying the gun industry isn’t culpable for many of the injuries and trauma caused by the products they make and sell. What I am saying is that I don’t understand how you can regulate any industry without bringing the representatives of that industry into the discussion as well.

              Those caveats aside, Fleegler and Lee have published a volume which everyone needs to read.  Got something better to do in the Age of Covid-19?

When Are We Really Going To Start Talking About Gun Violence?

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Last week I wrote a column raising concerns about the so-called ‘consensus-based’ approach to gun violence being promoted by physicians and public health researchers, many of whom seem to be convinced that as long as they claim to ‘respect’ the 2nd Amendment, that Gun-nut Nation will be more amenable to support all those ’reasonable’ gun laws, one such law having just been blocked by the Virginia State Senate.

This idea of not being opposed to the 2nd Amendment is a riff on another idea which started to appear in the medical literature when doctors began talking about counseling patients who own guns, the riff being the importance of ‘respecting’ the ‘culture’ of people who own guns. Here’s a sample of this approach from several of our most dedicated and respected gun-violence researchers:  ”The provider’s attitude is critical. Patients are more open to firearm safety counseling when providers are not prescriptive but focus on well-being and safety—especially where children are concerned—and involve the family in respectful discussions. Conversations should acknowledge local cultural norms; be individualized; and, when possible, occur within a well-established clinician–patient relationship.”

Given the fact that most physicians aren’t gun owners themselves, exactly how should these clinicians gain the knowledge they need in order to counsel about guns while taking care not to make negative judgements about ‘local cultural norms?’ The only peer-reviewed resource which attempts to define the cultural ‘norms’ associated with gun ownership is the research published by our friend Bindu Kalesan, who asked 4,000 respondents to report on the degree to which their social activities were in some way or another connected to their ownership of guns. What she found was that roughly one-third of the gun owners reported some degree of social contact with other gun owners.

Based on this research, should physicians assume that a patient who owns guns may also feel somehow identified with the social activities that revolve around gun ownership and gun use; i.e., shooting range visits, hanging around a gun shop, joining a gun club? Sounds fair to me.

There’s only one little problem. What do all these social activities involving guns have to do with reducing gun violence? Nothing. Why do I say nothing? Because the guys who go to the shooting range to sight in their beloved shotgun before hunting season, or the guys who stop off at the gun shop to play around with the latest toys on display, or the guys wandering around the gun show munching on a donut because the wife doesn’t need the grass cut or the driveway cleared that weekend, aren’t the folks whose behavior or culture or whatever you want to call it creates 85% of the injuries that we define as ‘gun violence’ each year.

That’s right. Assuming that intentional, non-fatal gun injuries run around 75,000 – 80,000 a year, add that number to the 15,000 fatal intentional gun injuries in 2017, and divide it by that number plus the 20,000 suicides.  Sorry, it’s only 83%. Of course, we know that all this mayhem is created by legal gun owners, right? Yea, right.

The public health ‘threat’ known as gun violence happens to be the handiwork of young men, most of whom live in inner-city neighborhoods and start fooling around with guns by the time they are 14 years old. And by the way, these are also the kids who have overwhelmingly dropped out of school, even though school attendance is never (read: never) used as an indicator of gun risk by all my friends doing all that public health research designed to ‘inform’ policy-makers about the efficacy of various ‘reasonable’ gun laws.

Want to sample gun culture?  Try: https://www.youtube.com/watch?v=0ZGJcV19gRw. After you watch it, watch it again. Then talk to me about how we need to ‘respect’ the culture of gun owners, okay?

What I am saying is simply this: Either we begin to talk realistically about the causes of gun violence or we don’t. Right now, we don’t.

Should We Ban Assault Rifles?

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              I normally don’t watch the Democratic debates because it’s still too early in the primary season and no matter who ends up with the nomination I’m going to vote blue every, single time. You see, I have this congenital physical ailment which when I get into a voting booth and reach for the Republican lever, my arm gets paralyzed and I can’t vote. I’m a bone fide gun nut and a yellow-dog Democrat and I’m proud of both.

              So I didn’t watch the debate last night but I did happen to see commentaries about the exchange between Buttigieg and Beto over Beto’s call for a mandatory buyback of AR-15’s. As I understand it, the media has decided that the Democrats are split between a ‘middle’ led by Joe and a ‘radical’ led maybe by Bernie, maybe by Warren, maybe by Ocasio, blah, blah, blah and blah. And the media has further decided that Buttigieg is somewhere in the middle while Beto is somewhere on the extreme. And what the media has decided is the acid test for where these two guys perch is over the issue of getting rid of AR-15’s.

              Now who would have ever thought that any kind of gun issue would be used to define the basic stance of the candidate who wants to lead the blue ticket in the national election next year?  I can see defining the candidates on something like universal health care, or whether or not to ‘tax the rich,’ or some other issue which hits in the middle of the must-do zone. But guns?

              Anyway, the argument between Buttigieg and Beto erupted because the kid from Texas has opted for a mandatory buyback of assault rifles, while Buttigieg wants to try and remain somehow relevant to Gun-nut Nation by saying that we can ask but shouldn’t require that gun owners turn over those lethal guns. And the way that Buttigieg is framing the argument is to challenge Beto to explain exactly how he is going to force assault-rifle owners to turn over their guns.

              Beto doesn’t yet have a plan to invoke the coercive authority of the government to get rid of all those black guns, but why should he be made to come clean on this issue when Liz Warren has promised to reduce gun violence by 80 percent without yet producing any plan at all? And let me tell you something about Lizzie; she produces position papers on just about everything under the sun. But so far we still don’t know how 120,000 fatal and non-fatal gun injuries each year will be cut down to 20,000 or less. So why should we expect Beto to explain how the government will pick up and throw out some crummy, semi-automatic guns?

              If this is the best that Buttigieg can do to vault himself ahead of Beto in the polls, I think he should go back to South Bend and figure out to keep the city parks neat and clean. That’s what municipal mayors are paid to do – collect the garbage, sweep the streets, make sure that everyone scoops up their doggie doo-doo, essential city services like that.  If someone asked me to go out and campaign for Buttigieg after he challenged Beto on something as stupid as whether an assault weapon buyback should be mandatory or not, to quote my old friend Jimmy Breslin, rather I should go lay brick.

              Mandating or not mandating a buyback of assault rifles isn’t going to make any great difference in how we deal with the violence caused by guns. What a buyback does, mandated or not, is to keep the issue of gun lethality where it belongs, namely, whether people understand the risks inherent in owning certain kinds of guns.

If you want to own an assault rifle and assume the risk, that’s fine. We all do risky things every day. But anyone who tells you that an AR-15 is just another ‘sporting’ gun is either lying or doesn’t know anything about guns.

How Should We Deal With Gun Violence?

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Turner Syndrome is a genetic abnormality which results from an absence or partial absence of the X chromosome, preventing the development of healthy ovaries in women, as well as certain heart defects.  It can be detected by genetic screening prior to birth, but sometimes a diagnosis doesn’t take place until the teen or young adult years. Once diagnosed, “girls and women with Turner Syndrome need ongoing medical care from a variety of specialists,” so says the Mayo Clinic. In other words, it’s a complicated disease.

How often does this disease appear? Roughly 1 out of 2,500 live births. If we take the best estimate for the number of fatal and non-fatal injuries caused by one person shooting a gun at someone else, the incidence of this type of gun violence within the age cohorts 16 through 34, would also be around 1 out of every 2,500 individuals in those age groups.

If we didn’t experience 90,000 fatal and non-fatal intentional gun assaults each year, it would be difficult to argue that gun violence should be considered a public health problem at all. But wait a minute, you say. What about the 20,000 people who end their lives every year by using a gun? Isn’t gun-suicide also a problem that needs to be addressed?

Of course we need to eliminate gun suicides but the issue in that instance is quite simple because overwhelmingly, people who commit gun suicides happen to use a gun that they legally own. And they use a gun because they know using a gun will almost always get done what they want to get done.

But that’s not the case with the homicides and aggravated assaults which account for more than 80% of all gun violence every year. This public health event is almost always committed by individuals who do not have legal access to the gun used in the assault. Which means that even before they use the gun to hurt someone else, they have already committed a serious crime. It’s called ‘illegal possession’ of a firearm which, under Federal law, can be punished by as much as five years in jail.

For all these reasons, I find it difficult to understand how my friends who conduct public health studies on gun violence seem to go out of their way to avoid contact with criminologists who have produced significant research on violent crime. I am referring, for example, to the study by Paul Tracy and Kimberly Kempf-Leonard, Continuity and Discontinuity in Criminal Careers, which analyzed the life histories of the 27,160 men and women born in Philadelphia in 1958, and followed them through 1984; in other words, from birth through age 26.

This longitudinal study allows criminologists to do what public health researchers do not do, namely, develop a profile of potentially high-risk behavior over time, rather than relying on one data entry for one point in time; i.e., when someone with a gun injury shows up for treatment in an ER. Here’s the bottom line: “The frequency of delinquent activity is the most consistent and strongest predictor of adult crime.”

What we get from public health gun research are the immediate symptoms which appear when the injury occurs. What we get from criminology is the case history leading up to the medical event. Can we really develop effective public policies to reduce gun violence without combining both?

This is why I began today’s column with a brief discussion of a medical problem – Turner’s Syndrome – that occurs within the overall population to the same degree as another medical problem – gun violence – occurs within the age cohorts which exhibit the overwhelming number of injuries caused by guns.

Diagnosing and treating Turner’s Syndrome is a very complicated affair. To repeat: it requires ‘ongoing medical care from a variety of specialists.’ Why should we approach gun violence in any less of a comprehensive way?  When it comes to gun violence, public health and criminology should stop avoiding each other and join together to solve this dread disease.

Khalil Spencer: It’s Not About Assault Rifles, It’s About Assaults On Decency.

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Along with the current discussion about gun control, assault rifle bans, and domestic terrorism, Uncle Sam is working on reinvigorating the nuclear weapons program in New Mexico and South Carolina. Given that a few of us in Northern New Mexico are affiliated with certain large Federal installations involved with making things that can create very large holes in the ground, I see a lot of chatter about both topics. This leaves me uneasy.

Guns and bombs are necessary evils albeit fascinating creations when not employed for their intended purpose. That’s why people enjoy shooting sports, especially with military design rifles, for example, as described here and here. But lethal weapons are solutions of last resort to real problems. Whether someone is kicking down your door or your frontier at o-dark thirty, you need a way to defend yourself. The problem is, when things get to the point of a shooting war, whether in the kitchen or the Ardennes, the less destructive solutions have failed or have been ignored. Cleaning up the blood and lost treasure gets more complicated as weapons become more advanced. During the American Revolution, a few thousand soldiers faced each other and opened fire when they could see the whites of each others eyes. The American Civil War, which bled America white, was the harbinger of WW I with trench warfare and the introduction of modern weapons. Nowadays, advanced heavy weapons and highly lethal infantry weapons (not to mention, nukes) can blow somewhat larger holes in the other side’s strategic interests. High capacity semiauto weapons can drench the neighborhood with a rainsquall of full metal jacket (or jacketed hollow point, I suppose). Or as Bruce Cockburn once sang, “who put that bullet hole in Peggy’s kitchen wall?”. Nowadays, it would be more than one hole. I think Bruce thought up that song when people generally shot at each other with revolvers.

Things won’t get better if we concentrate on more guns and bombs as solutions. There are more of us in the U.S. (and of course on the planet) and here at home, resources are becoming more unequal, leading to rising stress. Our civilization’s reliance on dinosaur juice, methane, and coal to power our cars, homes, and other stuff is on track to double atmospheric CO2 concentrations over Holocene levels by mid-century. This will, by most reputable accounts, lead to global energy retention via the Tyndall effect resulting in heating on the order of 1.5-4 degrees C and the associated climate adjustments that likely are associated with warming (sea level rise, changes in regional precipitation, changes in average temperatures, more extreme weather due to changes in the jet streams, etc). As an aside, note the uncertainties here. We can predict the big picture, but not the details, hence the constant bickering.

If you think forced migration due to climate and political problems is bad now, I suggest a friendly trip in the time machine to see what things will look like in a few decades. For those who are skeptical of forward climate models, we have plenty of historical geochemical records suggesting significant change is likely in the century to come. Even on the regional scale, we see the results on societies of past climate change in the abandoned settlements of the American Southwest and Greenland. I wrote something for the Albuquerque Journal about that here. Far fewer humans lived back then, so there were places to resettle. Where do people resettle in a few years, as their wells run dry and crops wither, now that we live in a No Vacancy world?

Our ability since the Industrial Revolution to change atmospheric chemistry and thus the atmosphere’s ability to retain the sun’s heat, in a nutshell, is why humans can profoundly – at least with respect to our own existence – impact climate.

me, in the Albuquerque Journal


My guess is we will probably deal with climate change using guns and bombs, since that seems to be the historical tradition. Yes, I am increasingly pessimistic. With the world order drifting towards authoritarianism, nationalism, xenophobia, and ethnic/racial extremism and increasingly, with people showing up unannounced at each other’s national doorsteps, I think the stresses will overcome reason. Plus, its been 74 years since we had a world war. Few living today remember what a world war looks like and frankly, I worry that today’s leaders can only see war as an abstraction. Reagan and Gorbachev knew WW II. Putin and Trump do not. My parent’s generation, now pretty much gone, saw it in its smoke, blood, and destruction filled reality.

The bottom line is if we continue to fixate on using Maslow’s Handgun to stave off change rather than hunkering down to fix what is broken, we will kick the underlying problems down the road until a crisis overcomes us and we solve the problems with…guns and bombs. Its the way Homo sapiens has always done it before. Why change now? Because the guns and bombs are too lethal to use? That’s the underlying idea behind deterrence, but it assumes rational actors acting in their best interest. Hmmm. Does anyone see a potential problem with that assumption? Orwell did:

The passage in the Declaration of Independence that starts, “We hold these truths to be self-evident,” with its references to equality, liberty, and happiness, is literally impossible to translate into Newspeak. “The nearest one could come to doing so,” Orwell wrote, “would be to swallow the whole passage up in the single word crimethink.”

Tom Stern, discussing Orwell’s idea of Newspeak.


As Kurt Vonnegut, who himself rode out the WW II Dresden firebombing, ironically enough in a slaughterhouse, would say, “So it goes“. Unless we choose otherwise.

Why Do We Believe That A Gun Keeps Us Safe?

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              Our friends at UC-Davis have just published an article on the connection between increased gun sales and gun-injury rates. The good news about the article is that it is open source, which means you can download it here and read it for free. So I commend Garen Wintemute and his colleagues for giving everyone in Gun-control Nation an opportunity to share their research findings for free.

              That’s the good news. After I summarize their research and what they learned, I’m going to mention the bad news. And the bad news is what Wintemute and his research team didn’t bother to learn. But first, here’s see what they learned.

              The research covers a ‘spike’ in handgun sales in California in California following the 2012 re-election of The Bomber and the Sandy Hook massacre, two events that occurred within a space of five weeks. The authors define a ‘spike’ as a “sharp and short-lived increase in firearm sales.”  From this, the authors then attempt to test the following hypothesis, namely, that “the sudden and unanticipated influx of firearms in a concentrated area such as a city could result in increases in firearm harm.” The research covered injury data from 499 California cities along with a complete run of handgun sales which are recorded individually and kept by the California DOJ.)

              Here’s where I have to raise a small, red flag. The authors claim that they measured the spike in gun sales from the date of Obama’s election until six weeks post-Sandy Hook. But what this analysis fails to consider is whether the spike was only a response to those two events rather than reflecting the release of pent-up demand which developed prior to Obama’s second win.

              I spent the entire Summer and Fall of 2012 sitting by myself in my gun shop because I didn’t know one, single gun nut who thought that Romney wasn’t going to be inaugurated President in 2013. Even Romney believed this fantasy and so did everyone else. Which is why gun sales collapsed during the run-up to that election, because everyone knows that when the White House is occupied by a Republican, the gun business goes into the toilet, prices collapse and why not wait a few months before buying your next gun? After all, it’s not as if anyone needs to buy another gun.

              If the UC-Davis researchers wanted to get a clear picture of the post-election spike, what they should have done was to factor in the trend of gun sales before the cataclysmic event took place. Gun sales always pick up in November and over the next three to four months, but the comparison should be judged not just by looking forward in time, but also by looking back.

              Did the researchers find an ‘association’ between the gun spike in November-December and an increase in gun injuries over the following year? Of course they did, although the percentage of gun injuries (4%) was substantially less than the percentage increase of handguns that were floating around. Again, I am somewhat leery of how the research team computed what they refer to as ‘excess handguns’ (meaning more guns being sold than were usually the case) because of the issue of pent-up demand.

Okay, now here comes the bad news.

We have all kinds of evidence that gun sales spike after mass shootings or other events that might portend new regulations reducing the availability of guns. Much of this research is referenced by the UC-Davis team. But to me, the question that really matters and that nobody in the public health research domain seems interested in understanding is this: Why do some people actually believe that a gun will protect them from the kind of harm represented by what took place at Sandy Hook?

If public health researchers like Wintemute and his colleagues would sit down and try to figure that one out, maybe just maybe we could hold a reasonable discussion with gun owners about the risk of owning those guns.

Is that too much to ask?

Why Do Physicians Continue To Support The NRA?

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              In 1927 a Belgian medievalist, Henri Pirenne, created an academic firestorm with the publication of an article which argued that the shift of Western Civilization away from the Mediterranean (Greece – Rome) to its modern locus in Northern Europe was due to the 7th-Century invasion by Islam into North Africa and Spain. His study provoked the publication of endless responses, revisions and refutations that probably accounted for an unknown number of academic promotions, tenures and teaching careers. When the whole controversy finally died down fifty years after it began, the center of Western Civilization was still located alongside the Île de France.

              I am reminded of Pirenne’s thesis whenever yet another pronouncement is issued calling for more research into the violence caused by guns, even though the formative research by Art Kellerman and Fred Rivara linking higher rates of suicide and homicide to guns in the home was published more than twenty-five years ago.

              The demand for more research has grown exponentially since Sandy Hook, just as the whole gun-control movement has spread outward following that terrible event. In April, 2015 eight national medical organizations published a ‘Call for Action,’ which demanded more “research to support strategies for reducing firearm-related injuries and deaths.” You can download this paper right here.

              Pursuant to that manifesto, three of the organizational signatories have produced their own calls for more research, agendas which allegedly reflect the various specialties which they bring to the issue of guns. I refer to pronouncements made by the American College of Emergency Physicians (ACEP) in 2016, the American College of Physicians (ACP) in 2018 and the American College of Surgeons (ACS), also in 2018.  You can download all three papers right here: ACEPACPACS.  Feel free to download the Kellerman-Rivara articles here and here.

              According to the ACEP, “high-quality firearm injury prevention research is needed.” Says the ACP, “More research is needed on firearm violence and on intervention and prevention strategies to reduce injuries caused by firearms.” Announces the ACS, “We recommend that research for firearm injury and firearm injury prevention must be federally funded at a level commensurate with the burden of the disease without restriction.”

              So there appears to be a consensus emerging within the medical community that a behavior which results in injuries to more than 125,000 Americans each year is a serious problem and that more research will help develop effective interventions to bring that number down.

              With all due respect to the 39 signatories of these pronouncements who hold MD degrees, what they have published are road maps to help them design and produce more studies to enhance their research careers. Thank you very much.

              The behavior which creates gun injuries is well known – pick up a loaded gun, aim it at yourself or someone else, pull the trigger and an injury occurs. It’s guaranteed to work every, single time. If any one of the 39 medical researchers believes this research to be inadequate, come to my gun shop, we’ll go downstairs to my range, I’ll give you a loaded gun, then you pull the trigger and let’s test the result. Sorry folks, this outcome is validated at least 350 times in America every, single day.

              Incidentally, these three medical groups – ACEP, ACS, ACP – donated nearly $250,000 to the 2016-2018 Congressional campaigns of the worst, most aggressive members of the House GOP caucus whose votes have been primarily responsible for the lack of gun-research funding which these organizations all claim to be their most worrisome concern. Have any of these researchers who are so committed to saving lives said one word about this egregious state of affairs? Not one peep. And these researchers want their concerns about gun violence to be taken seriously by anyone other than themselves? Are they serious? You can download this wall of shame right here. You can also read a new JAMA article which goes in greater detail about medical support for the NRA.

               The research on gun violence is clear: get rid of the guns. I say this as a bone-fide gun nut, not just as some doctor who happens to own or not own a few guns.

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