A Public Health Response to Handgun Injuries: Prescription -- Communications and Education Nicholas Johnson American Journal of Preventive Medicine, May/June 1993, pp. 47-51 [Am J Prev Med 1993;9(suppl 1):47-51] # # # Anything that unnecessarily contributes to human disease, injury, or death is a proper concern of public health, including firearm deaths, which now total 35,000 a year. Public health's role is to reduce these firearm injuries and deaths. A total handgun eradication program might be useful toward this end, but this article is limited to the techniques of education and communication. Such approaches have been helpful in reducing disability and death from high blood pressure and tobacco. I suggest specific communication and education programs to reduce firearm injuries and death. Examples include school programs about alternative (to violence) dispute resolution, information regarding alternative, nonlethal weapons, and the contribution of personal weapons to injury and death. # # # An Opening Musical Number On a warm Washington summer day in July 1969, seven Federal Communications Commission (FCC) Commissioners were sitting behind the bench in the seventh floor hearing room at 20th and M Streets, responsibly trying to stay awake until lunch. High-priced lawyers in three-piece suits droned on throughout the morning, creating their best case for the programming offered to the American people by their clients, the networks. Around noon, about time for the luncheon recess, a bearded fellow in open-necked shirt, guitar in hand, appeared through the back door. "Just a minute," he shouted from the back of the room, "l have something to say about this." It was Mason Williams, Emmy-winning head writer and performer for The Smothers Brothers Comedy Hour, and composer of the popular song "Classical Gas." He had brought with him a handwritten document. The FCC Chairman, Rosel Hyde, was so taken aback that he permitted Williams's performance to postpone the commission's regular noon lunch break, for the first time.l Mason Williams proceeded to sing, talk, and one-line his way through what was later published as "The Mason Williams F.C.C. Rapport."2 And, after the initial shock, no one complained. He closed with one of his songs, "Cowboy Buckaroo." I was raised on matinees on Saturday afternoons looking up at Hoppy, Gene and Roy oh, boy and I grew up a thinking the best a man can do is be a rootin' tootin' straight shootin' Cowboy Buckaroo. A hush fell over the hearing room when he finished. "Hey," he said, "I am telling you the truth. I am like the entertainment I grew up on." To the only applause ever heard in that stuffy hearing room, he packed his guitar, walked out the back door through which he had entered, and left behind a stunned pack of lawyers and bureaucrats who would never look at TV in quite the same way again. In the short space available here, I will touch on a number of issues related to "Cowboy Buckaroo." What is "public health"? How are handguns related to public health? How can we reduce handgun injuries and fatalities? And how might mass communication and educational programs contribute to the problem--and the solution? What Is Public Health? During the three years I have been codirector of the University of Iowa's Institute for Health, Behavior and Environmental Policy, I have been surprised by the difficulty of explaining public health. For most people, most of the time, any use of the word health is firmly tied to images of doctors, hospitals, operating rooms, and drug stores. Seemingly one cannot think of the term other than in connection with the delivery of medical services for the treatment of injury and disease. No one can question the importance of the public policy issues surrounding the delivery of medical services in our society. For starters, the cost is rapidly approaching one trillion dollars a year3--enough to get almost anyone's attention. And yet, despite the fact that the United States has the highest medical costs in the world, many Americans lack access to adequate medical care.4 So it is appropriate that these public policy issues should be the focus of Congress, state legislatures, and the medical establishment. But public health programs--and public policy issues--often seem virtually unrelated to medical services. One example: some 15 million of the world's children die needlessly each year.5 That is more than five times the entire population of Iowa. The cause of their deaths has almost nothing to do with medical services or research. It relates to the impurity of the drinking water and the lack of sanitation where they live. That is a problem of public health, public policy-- not doctors and hospitals. The engineering is simple; the law is simple. Only political will is needed--but is absent. So 15 million die. Another example: tobacco. Almost 450,000 Americans die every year from the use of a product that, if used for the intended purpose, will kill them.6 Medical science can, sometimes, extend the lives of those dying from tobacco-induced diseases. But the only meaningful cure for these illnesses is the avoidance of the lethal product that causes them. Medical services and research can do little to help. This is a public health problem. Public health is the enhancement of good health, the prevention, rather than simply the treatment, of disease. Public health does not just reduce the cost of delivering medical services (this soon-to-be $1 trillion medical bill); its goal is to eliminate some of those costs. Handguns and Public Health How on earth do handgun injuries relate to public health? Anything that unnecessarily contributes to human disease, injury, or death is a proper concern of public health: unsafe tractors and other farm equipment, cancer-causing agents in a city's water supply, asbestos in buildings, foods high in fat and sodium, lead in gasoline and mercury in swordfish, the lack of exercise programs for our children and ourselves. If enough people were injured and killed in hang glider accidents, hang gliders would become a concern of public health professionals (as, for example, motorcycles are today). So, in that sense, when firearm deaths reach 35,000 a year,7 when they become the leading cause of death for black men between 15 and 35 years of age,8 the federal agencies responsible for watching over the nation's health--the Centers for Disease Control and.Prevention--begin tracking those injuries and fatalities as they would those from any other cause.9 Public health is not a political matter. It has nothing to do with whether or not you are a member of the National Rifle Association (NRA), like to hunt, or have guns of your own. From a public health perspective, we have an obligation to try to understand, and then minimize, the thousands of deaths and injuries associated with firearms. (Deaths from guns, though the most dramatic result, are not the only impact of guns. The psychological impact of threats from guns and injuries [as distinguished from death] are far more numerous. Kleck and McElrath7 project that roughly half the time an aggressor confronts a potential victim, there is only a threat without an attack. In those half of the cases including an attack, about one half result in injury and one half are uncompleted. When injury results, most of the time it is nonfatal. Death results in 1.4% of the cases involving injury. Only about one in six gunshot wounds results in death.) Some public health professionals tend to prefer "fail-safe" solutions to public health. Fluoride reduces the number of cavities in kids' teeth.10 Putting it in the city's drinking water is a more failsafe way to accomplish that end than educational programs explaining the benefits of using a fluoride rinse regularly. Relying on air bags to inflate at the time of an automobile crash is a more fail-safe way to reduce automobile injuries and death than hoping that passengers will remember to fasten seat belts every time they get in the car. Fluoride in drinking water and air bags in cars were not simple or easy political accomplishments. Neither are the fail-safe solutions to handgun injuries: limitations on ownership of handguns, up to and including the possibility of their elimination. But there has been political progress even here. From 1980 to 1985, the number of Iowans willing to support severe restrictions on handgun ownership increased almost 100%. Washington, D.C, often thought to be the murder capital of the United States, actually caused a temporary 20% reduction in suicides and homicides as a result of a new law radically curtailing eligibility to own handguns.11 Although handguns are used by some for hunting, target practice, or collectibles, these weapons are usually designed, sold, and purchased for the sole purpose of, if necessary, injuring or killing another human being. Death is not, as with tobacco, a likely by-product, it is the only purpose of the device. However, the resulting deaths involving handguns are both intentional (suicides, homicides, self-defense) and accidental (including gun use by children). Strategies for reducing handgun injuries and fatalities must reflect that distinction. Although intended to kill, guns could be designed to reduce the likelihood of accidental death. NRA and other educational programs on the handling of guns help.12 But assume a handgun is owned by someone who is prone to seek violent solutions to problems (which may have prompted the purchase in the first place), who engages in spouse and child abuse, is often depressed, or is intoxicated much of the time. So long as that person's right to own a handgun is preserved, little can be done to reduce the possibility that, at some point, that gun will be used to injure or kill someone. Strong emotional and intellectual arguments can be made both for and against a handgun ban and eradication program. But my task here is not to advocate either of those positions or those involving any of the other proposals for licensing, annual registration, tort liability for manufacturers, dealers, and owners, and so forth. This article explores additional educational and communications efforts to reduce the incidence of firearm injury and death. But such programs are limited. The public health reality is that we live in a nation with 35,000,000 handguns and some of the highest rates of handgun injury and death in the world.13 (Some estimates of the number of handguns are higher. The New York Times, July 9, 1985, p. 16: "There are an estimated 40 to 50 million handguns in the United States, with approximately 2 million more being manufactured annually." Christoffel K, Christoffel T. Handguns: risks versus benefits. Pediatrics 1986;77:781-82: "55 to 60 million . . . handguns." A.M.A. Council on Scientific Affairs. Firearms injuries and deaths: a critical public health issue. Public Health Reports 1989;104:111-20.) So long as we are unwilling to adopt effective, fail-safe solutions--actually removing these instruments of carnage from our midst--the price exacted for this "freedom" will continue to be thousands of lives of children and adults. Reducing Handgun Injuries--Education and Communication What can mass communications and educational programs do to improve public health? Often, it turns out, quite a lot. Not many years ago, roughly one in eight people with hypertension were getting the treatment to check their problem. Today, the ratio is one in two. This radical improvement in public health occurred, not as the result of increased medical research or improved medical treatment, but as the result of an extraordinarily inexpensive program in public (and physician) communication and education. The impact of communication and education on tobacco-related diseases is also apparent. Some groups, such as women, now show rising rates of lung cancer, attributable to their adoption of smoking habits as teens.14 But we are still benefiting from a relative decrease in overall use directly traceable to the so-called antismoking public service announcements mandated by the FCC and briefly seen on TV over 20 years ago.15 Many other examples illustrate public health change. The use of seat belts by characters in episodic television has a positive impact on drivers in the real world. The Harvard School of Public Health is working with the creative community in Hollywood to include reference to designated drivers whenever alcohol is involved in soap operas or evening entertainment programs.16 And there are also examples of the opposite effect. There are many attempts to explain why America seems to be one of the most violent nations on earth: our historical origins, the glamorization of the western frontier traditions, our ethnic and cultural diversity, the failure to respond to the needs of our underclass. But one hypothesis that continues to emerge from a variety of disciplines is the relationship of televised (and feature film) violence to violence in real life. More than 2,500 studies and numerous official and unofficial task force and study commission reports support this hypothesis.17-20 The average kindergarten student has already received more hours of instruction from television than the number of hours he or she will later spend sitting in college classrooms earning B.A. degree.21 (As I said some years ago: All television is educational television; the only question is, "What is it teaching?"22) By the time those five-year-olds reach their teenage years, they have seen 13,000 televised murders (most involving seemingly little pain or consequence) portrayed as the approved adult way of resolving conflict and dealing with anger.23 As children, they are given the toys of violence and battle (GI Joe dolls are among the top-selling toys).24 As students, they associate with colleagues who are members of warring gangs. As young adults, they see their nation's entertainment focus on football fields of play, its foreign policy out of focus on fields of battle. Even if not supported by academic research, common sense suggests some connection between the myths on which our culture is based (now emanating from Hollywood on videotape) and the lives we lead. We should not be stunned when a young boy who, like Mason Williams, spends his youth looking up to a "Cowboy Buckaroo," then grows up to behave like one. Much can be, and is being, accomplished by the NRA, Isaac Walton League, and others to educate and inform about the hazards of handguns. Such educational and communications programs can be expected to help reduce accidental handgun injuries and deaths. But what about the far more common, intentional handgun injuries? It seems unlikely that someone who is prone to anger and violence will recall, or care about, what they have been told about the taking of life. The solution is unlikely to be found in just informing gun owners about their weapons' lethal qualities. The Root of the Problem and an Educational Opportunity Perhaps educational solutions to the handgun injury problem require a broader perspective than that inspired by looking down the barrel of a gun. The role and causes of violence in our society, whatever the reasons, should become our focus. Hate crimes are on the rise, even in Iowa.25 The risk of being murdered is now twice what it was three decades ago.26 One million women a year seek medical aid for domestic abuse.27' Millions more say nothing. Yet the children or spouses who are beaten black and blue are still alive, even if just barely. The ones who were shot are likely dead. To them and their doctors, whether a gun was available to their assailants is enormously important. If the tendency to use guns to deliberately harm others derives from the same root cause as the desire to pummel another with one's fists, we may discover that, in trying to solve the former problem, we come to understand and solve the latter as well. Educational programs in our schools today, those that could be used more widely, may have the positive long-term impact of reducing all violence, including that inflicted by handguns. There is some evidence that those youngsters who are abused as children, whether physically, sexually, or emotionally, develop increased propensities to violent behavior themselves in their teens and later years. Thus, programs directed at reducing child abuse ultimately may have an impact on reducing handgun injuries and fatalities. Some would say the problem is even broader, and that we will never significantly reduce violence until we are prepared to create a society in which all our citizens have access to quality health care and adequate nutrition, housing, education, and an opportunity for jobs that bring self-esteem as well as a decent standard of living. There are other alternatives to the alleviation of powerlessness than guns. Nor are all handgun injuries and fatalities inflicted on others. Some are deliberately self-inflicted in suicide attempts. Of course, potential suicide victims who have ready access to handguns are more likely to select them as their weapon than those who must first purchase guns. But whoever is fully determined to kill him- or herself has a wide choice of means. Thus, in these cases as well, reductions in the incidence of handgun suicides may be increased by a broader focus on suicide prevention programs generally. To the extent suicide is associated with low self-esteem or depression, educational and mass communications programs (or programs aimed at early identification of those individuals who might respond to counseling, drugs, or other treatment) might well be useful in reducing suicides with handguns as part of an overall reduction in suicide rates. Some Specific Proposals A state legislature can do much in the areas of information, mass communications, and education about handguns. Of course, there are the limitations imposed by the First Amendment, preemption by the FCC, and the tradition of local control of schools, to name a few, but any legislative action must accommodate restraints. And legislators can certainly act as opinion leaders and voices of common sense. Here are some possibilities: 1. Everyone should understand handgun injuries and fatalities as a public health problem of substantial proportions. 2. Every legitimate effort should be made to inform the public--through educational programs in the schools, public service announcements on the electronic media, newspaper and magazine stories, and government publications--of the facts about handgun injuries and deaths. They should know the numbers and risks of injury and death and should realize that their handgun will more likely be used on them than by them, that childhood deaths are a real risk. 3. Those who feel insecure without some protection from assault should be encouraged to acquire nonlethal weapons that could be equally effective in deterring crime without high risk of death to themselves and others. Examples might include dogs, chemicals, whistles, lights, alarms, or stunguns. Those who insist on having conventional handguns should be instructed in their safe storage and handling. Tort liability, to the extent it is imposed on those who manufacture, sell, or possess handguns producing injury or death of others, should be widely publicized. 4. Citizens should be encouraged to notify program producers, networks, advertisers, cable systems, individual stations, movie theaters, and video rental stores of the public health consequences (and their disapproval) of the gratuitous use of violence in story lines.28 Praising the efforts of those who choose nonviolent themes and solutions, or even confront violence and alternatives to it, is equally important. 5. Public schools should be encouraged to use available teaching materials about the best ways to handle anger and nonviolent resolution of disputes. Perhaps this material could actually be included as a part of the health curriculum, so that violence could be seen as the public health problem it is and alternative dispute resolution techniques could be portrayed as "good for your health." Techniques of arbitration, negotiation, and mediation, among others, can be adapted for children's use. 6. The mass media and school staff should discuss more fully and widely the real consequences of handgun injuries and fatalities. Some protest violence on TV while others argue that there is not enough real unsanitized violence; we are left unaware of the impact of death on family and friends, of injury on someone suffering excruciating pain and disabled for life. Some states memorialize those killed in highway accidents with crosses at the site of death, or bodies drawn on the pavement. Handgun deaths might be similarly memorialized. 7. Information about gun ownership could be more thoroughly gathered, updated, and made publicly available. Automobile drivers are tested, examined, and licensed (subject to loss of license for drunk driving and other serious offenses), in large part because of the risk of permitting unqualified drivers to operate such potentially lethal equipment. A comparable process for handgun owner licensing does not seem unreasonable. Coupled with an annual reregistration of handguns, this process would enable the tracking of those who failed to reregister. It would also make possible identifying gun dealers by the names of those killed with guns they sold. Making this kind of information public, through newspapers and publicly accessible computer data bases, would forewarn the general public. CONCLUSIONS The numbers of handgun injuries and deaths have reached epidemic proportions. Handguns are a public health problem. But there are solutions, some involving the more creative and effective use of mass communications and education. The films mentioned in Mason Williams "Cowboy Buckaroo" and the modern televised equivalents help create our violence-prone society. Some suggest that the rate of increase in that violence follows, by almost exactly 20 years, a parallel rate of increase in the number of television sets in a society. But education and the media can also be the instruments of positive change in public health, as illustrated by the reduction in tobacco use and the increase in the percentage of hypertensive patients getting effective treatment. Another verse to Mason Williams's song, omitted at the outset, can serve even greater purpose here: Should we be the way we are Or be how we could be? Could illusion become reality? I've got to ask the question 'Cause the answer's overdue. It certainly is overdue, and we buried another 35,000 bodies last year to prove it. Is a "kinder, gentler nation" possible? "Could illusion become reality?" Of course it could. But all the world-class doctors, medical research, and hospitals in the world cannot help us on this one. Handgun injuries and fatalities are a public health problem. This is one we have to solve by ourselves. REFERENCES 1. Will FCC finally give up on 50-50? Broadcasting Magazine. 1969 July 28:50-52. 2. Williams M. The Mason Williams F.C.C. Rapport. New York: Liveright, 1969. 3. Sullivan L. From the Secretary of Health and Human Services. JAMA 1990;264:1091. 4. Hass F. Patients leaving emergency departments without being seen by a physician. JAMA 1992;267:231-4. 5. Perry V. U.N. reports pollution killing millions of children. The Reuter Library Report 1990 June 6. 6. Fiore MC. The new vital sign: assessing and documenting smoking status. JAMA 1991;266:3183-4. 7. Kleck G, McElrath K. The effects of weaponry on human violence. Social Forces 1991;69:669-92. 8. Fingerhut LA. Firearm homicides among black teenage males in metro counties: comparison of death rates in two periods, 1983 through 1985 and 1987 through 1989. JAMA 1992;267:3054-8. 9. Mercy J, et al. [Letter]. Issues in Sci Tech 1991:18-20. 10. Boughman J. The pure truth: on the anniversary of the Perrier recall, there are more doubts than ever about bottled water. Health 1991;23:44. 11. Loftin C, McDowall D, Wiersema B, Cottey T. 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Exposure to television as a risk factor for violence. Am J Epidemiol 1989;129:643. 21. Johnson N. Test pattern for living. New York: Bantam Books, 1972. 22. Johnson N. How to talk back to your television set. New York: Bantam Books, 1970. 23. Gerbner G, Signorielli N, Gross L, Morgan M, Jackson-Beeck M. The demonstration of power: violence profile no. 10. J Communications: 1979;29: 178. 24. Downing N. Playskool climbing the hill. The Providence Journal-Bulletin. 1990 July 15:F1. 25. Peirce N. Recurring nightmare of hate crimes. Natl J 1990;22:3045. 26. Garnerman E. Crime on the rise in Arizona, report says. States News Service. 1992 Jan 10. 27. Raymond C. Campaign alerts physicians to identify, assist victims of domestic violence. JAMA 1989;261:963-4. 28. Carton P. Mass media and young people. Nieman Rep 1991;Winter:24. # # # *** Copyright c 1993 by Nicholas Johnson and the American Journal of Preventive Medicine/Oxford University Press. 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