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A public health response to gun violence in America

Public health workers try hard to balance individual and public rights – ensuring that someone who refuses treatment for infectious tuberculosis has access to due process before being quarantined and required to take medications. How do we apply this equation to guns?

Esther Chernak is a physician and director of the Center for Public Health Readiness and Communication at Drexel University School of Public Health, where she is an associate research professor.

By Esther Chernak

One of the fundamental challenges in the practice of public health – the work that keeps populations and communities healthy and safe – is balancing the rights of the individual with the rights of the public. We work hard to make sure that a person with active tuberculosis who refuses treatment has access to due process before they are deprived of their civil liberties and required to take medications and confined so they don't infect others.

We are responsible for identifying restaurants that sell unsafe food and companies that sell unsafe medications. The public whose health we are committed to protecting expects that those businesses will be shut down until their products are no longer dangerous.

This week, we watched helplessly as innocent children and their teachers were slaughtered in an elementary school in Newtown, Connecticut, another tragedy arising from our failure to regulate access to firearms and to address serious mental illness. This is a tragedy that recurs too frequently now and, given the horrific events at Newtown, we are at a reckoning— we need to develop a clear sense of what our society should look like moving forward, we must quickly make decisions about what resources we will need to make the world safer for our children, their teachers, and just everyday citizens, and, finally, we need to confront the implications of such changes on how to balance the rights of individuals with the health and safety of our communities. The practice of public health has a great deal to teach us in these areas.

Not surprisingly, the first discussion we must have is about the easy access to guns in the United States. Anyone with a credit card or ready cash has seemingly unfettered access, the Irish Times reported, with a perspective that reflects much of the world's disbelief with American right-to-carry culture, to hand guns, automatic weapons, and ammunition. This access has contributed to high profile tragedies across the United States – in Columbine and Aurora, Colo.; at Virginia Tech; in Oak Creek, Wisc.; in Tucson, Ariz., and now in Connecticut. A recent survey of 62 gun massacres in the United States shows that "of the 142 guns purchased by the killers, more than three-quarters were obtained legally."

Weak gun laws also contribute – in lower profile, but with no less tragic consequences – to a plague of homicides by firearm in cities like Philadelphia, Chicago, Detroit, New Orleans, and Miami. Somehow, the slow, steady accumulation of casualties from daily gun violence has become, for many, too easy to ignore as our elected officials struggle not to head over the fiscal cliff, or manage the conflicts overseas that threaten our national security.

But the events in Newtown demand our attention, and we need to understand that after a steep decline in the 1990s, gun violence has increased in our nation, and threatens our safety no less than these other issues. Restricting access to guns through better enforcement of laws that are already on the books and through new legislation at the state and federal level will be important. We need to identify the gaps across systems and states that allow people access the types of firearms whose only appropriate use is in combat in Iraq or Afghanistan. And we need to have the willpower to restrict that access.

We must also acknowledge and deal with the fact that violence has become part of our popular culture. Acts of violence are glorified in movies, music, videos, and in the electronic games whose popularity has surged in recent years, particularly among adolescent boys. This culture of violence trivializes its actual impact. Do the young men who absorb images of macho, gun-toting characters, in the world of fiction and in real life, realize the permanent and fatal costs of gunshot wounds before it is too late?

The second conversation to have is about how we handle mental illness in this country. Fueled by a combination of good intentions and dwindling resources, we have slowly dismantled a public mental health system that has limited resources to deal with dangerous psychiatric illnesses. No longer do we hospitalize individuals with profound mental illness: the Byberry's and state institutions shuttered their doors long ago. Instead, we rely on a fragmented, under-resourced system of outpatient providers, crisis mental health emergency rooms, and short-term psychiatric hospitalizations with uncertain follow-up of patients with critical problems. Families are on their own to manage major mental illness in their relatives and loved ones, a situation that can lead to deadly consequences.

The absence of an accessible, robust system to deal with mental illness is compounded by the shame of acknowledging that it exists. Earlier this year, in my own primary care medical practice in a community clinic, I had to involuntarily commit (obtaining a "302 warrant" in medical parlance) two different patients who threatened to commit suicide. The experience was brutal. Both had confided their intention to take their own lives, but did not want to seek care for that impulse. They were taken by police to the local psychiatric emergency room, in handcuffs. There are abundant reasons for this procedure, all good and designed to protect everyone involved, but that does not make the reality of it any easier. And this commitment, for 72 hours unless a ruling of a court extends it or the person elects to remain in care voluntarily (which both of my patients ultimately chose to do), is still insufficient for many with serious psychiatric illness. Upon discharge, they are on their own to seek further counseling, take or not take their medications, and hopefully not harm themselves or others.

Will my patients confide in me again if they feel those dangerous impulses? I am not sure.

As a society, we are often uncomfortable with illness in general, but there is significant stigma around mental illness for those who live with it and for their family members. We have to be able to talk about it without embarrassment if we are to come to grips with its impact on both individuals and society. This is an appropriate time to take a hard look at the mental healthcare system, the resources we devote to it, and the supports that we provide to providers, patients, and their families when it comes to recognizing and treating psychiatric disease. We need a system that offers something other than short-term and long-term incarceration for people who suffer from serious mental illness, but also protects us from people who might be dangerous – granted, a difficult judgment to make sometimes.

We are also uncomfortable, perhaps more so than residents of other countries, with depriving people of their rights – to live freely, to sell goods and services, to own guns. But we recognize that there is a limit to the exercise of those personal rights when they infringe upon the health and welfare of others. Even if it means restricting the rights of a few, for the benefit of the community.

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