Krishna Chinthapalli on the questions around gun control in the US

It is the 13th leading cause of death, between liver cirrhosis and renal failure. There are more and more frequent outbreaks—a record seven in 2012 with over 140 deaths. The agent responsible is known, and has largely been eradicated in many other developed countries. But in the USA, federal money is not used to investigate it. In Florida, a law was passed to prevent doctors from asking patients about it.

I’m talking about guns of course. On the darkest day of 2012, we heard an incredible response from the National Rifle Association to the school shootings in Connecticut. Its chief executive, Wayne LaPierre, pinpointed the causes for the massacre. They were not guns. They were society, the national media, the national media’s corporate management, the national media’s stockholders, federal prosecutors, hurricanes, terrorist attacks, the video game industry, Hollywood, music videos, police officers, parents, Barack Obama, foreign aid, politicians, and the lack of a database of the mentally ill. That’s a comprehensive list of causes, and we must all be grateful for the painstaking research that must have gone into it.

Unfortunately, not everyone agrees. Mayor Bloomberg of New York called the statement a “paranoid, dystopian vision” but then again, he is a politician and owns a national media company so of course he would. Going back to the NRA statement, it would be easy to be disheartened and wonder how we can tackle the world’s terrorists, the police force, the chief of the army, the US entertainment industry, and God. However, LaPierre knows the solution: more guns.

No, no, I know you’re thinking “What a great idea! If everyone went out shooting, then there’d be nobody left to shoot,” but that isn’t what he has mind. LaPierre and the NRA believe in instituting a National Shield programme in which there are armed guards in every school to stop future killings. Right now—“This is the time, this is the day for decisive action. We can’t wait for the next unspeakable crime to happen before we act… We must act now,” said LaPierre.

For those who haven’t rushed out to patrol their school grounds, let’s think about the idea of armed guards. One investigation found that out of 62 mass shootings in the USA over the last 30 years, not one was stopped by an armed civilian, although in one case a civilian chased an attacker afterwards he had left the scene and then shot him dead. As for armed guards at school, Columbine High School had two armed law enforcement officers present during the infamous shooting that left 13 people dead. Even if guards were a deterrent, the next problem is whether that means having armed guards in cinemas and temples too (in which two shootings also occurred in 2012).

Where does this stop? Do physicians have a role in this conversation?

Guns are a public health issue, and a major one at that—the American Medical Association, American College of Physicians, American Academy of Pediatrics and the American Academy of Family Physicians agree.

In 2009, the most recent year with final data, the Centers for Disease Control and Prevention reported that there were 31,347 deaths from firearms. These can be broken down: 18,735 due to suicide (half of all suicides), 11,493 due to homicide (two-thirds of all homicides),  554 due to accidents, 333 due to legal intervention, and 232 that are unclassified.

The good news is that the homicide figure is showing a downward trend, part of a general decrease in violent crime trends in the USA. The bad news is that the figure compares badly with other countries, for example, a total of 41 homicides by firearms in the UK. This means that in one year in the USA, the chance of being shot is about the same as throwing seven dice and getting seven sixes. In the UK, the chance of being shot is the same as getting seven sixes from seven dice and then throwing two more dice and getting two sixes. The overall homicide rate is less dramatic: about three times lower in the UK than the USA.

Gun politics are restricting epidemiological research in the USA. The Centers for Disease Control and Prevention and the Department for Health and Human Services have specific provisions in law preventing the use of funds for anything “to advocate or promote gun control.” Using research funds for lobbying is prohibited anyway, and no other research topic is mentioned so explicitly.

The origin of these provisions is thought to be due to the NRA’s lobbying. The catalyst was CDC-funded research showing that firearms did not increase safety. One of these studies, in the New England Journal of Medicine, found that keeping a gun at home was associated with an increased risk of homicide.

Population studies by the Harvard School of Public Health have also found a link between more guns and more homicides—even as one of the authors complains of “the pressure the gun lobby has put on funders.” Gun ownership also seems to be associated with an increased risk of accidental death at home, suicide, and death from domestic violence, according to the Law Center to Prevent Gun Violence.

A third point is that gun politics is affecting clinical medicine. Florida’s state legislature passed a law in 2011, which prevents doctors from asking patients whether or not they keep a gun in their house. Thankfully, the law was blocked by a federal judge, but the state and the NRA are appealing the ruling. Alabama, Minnesota, and North Carolina have considered such a law as well.

Obama’s Affordable Care Act interestingly has an amended clause entitled “Protection of Second Amendment Gun Rights.” Here it is stated that patients are not required to disclose gun ownership status to any public health programme, to any health organisation, or to any other form of data collection. Furthermore, the clause states that the act will not allow for keeping a record of gun ownership, and insurance companies are not allowed to change insurance premiums on the basis of gun ownership. How did this get into the act? Well, perhaps it is testament to the influence of the gun lobby. One anonymous staffer, working in Congress, said of the NRA. “We do absolutely anything they ask and we never cross them… They’ve completely shut down the debate over gun control.”

Finally, what about the idea that fewer guns may help reduce shootings? Well, in 1976 the District of Columbia had the same idea and banned all handguns. During the first eleven years after the ban, firearm related homicides and suicides both fell by a quarter, with no change in other means of homicide or suicide. This did not appear to be part of a broader trend as there was no change in neighbouring areas without a ban. It was thought that 47 deaths a year were prevented.

In 2008 the Supreme Court overturned the ban because it violated the Second Amendment – “the right to keep and bear arms.” As some point out, the firearm-related homicide and total homicide rates have fallen again by about 25% since the ban was overturned, but then again they have been slowly falling since 1993. The data is by no means clear-cut, and some think most of the changes in the rates relate to less use of crack cocaine, social reform, and gentrification. The message here is that more research needs to be done.

The National Research Council came to the same conclusion in a critical review of the evidence on firearms and violence, stating “The committee found that answers to some of the most pressing questions cannot be addressed with existing data and research methods, however well designed… If policy makers are to have a solid empirical and research base for decisions about firearms and violence, the federal government needs to support a systematic programme of data collection and research that specifically addresses that issue.”

I am not arguing for gun control. I am arguing against embedding a firearm presence in schools and colleges without further thought. That is not what is needed. Instead, there needs to be more federal research into gun policy. Gun ownership and safety need to remain a legal topic of discussion in the clinic, and the effects of gun lobbying practices need to be made transparent to all.

Krishna Chinthapalli is the BMJ clinical fellow.