Category Archives: Firearms

Are we making progress or falling behind?

Posted by on May 27, 2013 Comments Off on Are we making progress or falling behind?

In health care we don’t need to look far for bad news. In the past week, I have read:

  1. The prevalence of diabetes has increases 75 percent from the early nineties to the late naughts. A more extensive discussion (may require free Medscape subscription registration) is at New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic
  2. Leapfrog Hospital Safety Scores ‘Depressing’
  3. Study finds jump in ER-related admissions

And certainly we could include partisan bickering in Washington among politicians more focused on the next election than any meaningful policy debate or measures.

However, the simple fact is that none of this matters. We have no choice. If we do not adequately address our health care needs, then we will no survive as individuals or as a society.

If that premise, the premise of this blog, is correct, then we must assure access to healthcare for everyone. We must get the public health epidemics of obesity, diabetes, and gun violence, among others, under control.

On this Memorial Day, as we reflect on how many Americans have given up their lives at a young age to protect the American experiment, let us consider our debt to them: we owe it to them to insure that our society does not fail and that individuals not on battlefields do not give up their lives at a young age because they ate too much or someone bought a gun out of fear.

We are Americans: we do not accept failure in ourselves. The rest is trivial distraction.

Are we doing ourselves in faster than we think?

Posted by on May 6, 2013 Comments Off on Are we doing ourselves in faster than we think?

We know that our health is adversely affected by obesity, a sedentary lifestyle and fat consumption, not to mention tobacco and lack of access to healthcare. These factors are holding down what should otherwise be continued gains in life expectancy. They also adversely affect those who survive: the strains of obesity on the skeletal structure, emphysema from tobacco consumption, chronic heart disease, cancer that takes over lives, etc.

Recent studies indicate that not only are we experiencing indirect and long-term impacts on our lives and health, but the rate of suicide is increasing, surpassing deaths by motor vehicles in 2009. What adverse lifestyles are not doing to us in the long-term, we are doing directly to ourselves in the now.

The recent CDC study Suicide Among Adults Aged 35–64 Years — United States, 1999–2010 showed that the largest increase in the suicide rate was among whites between ages 45 and 64, in contrast to the common concern about teen and geriatric suicide.

In general, the suicide rate is related to stressors and the availability of means. The following chart, with data from the National Vital Statistics system, is from that CDC study:

Suicide by Sex and Means 1999-2010

Noteworthy are the increased use of firearms, which account for about half of all suicides among men, and suffocation (euphemism for hanging). The study lists the rates of suicide by state as well as the rate of increase from 1999 to 2010. I wondered about the ownership of firearms in those states.

I found that the study, “Association of suicide rates, gun ownership, conservatism and individual suicide risk,” was published online in the journal Social Psychiatry & Psychiatric Epidemiology in February.

The title a bit provocative, but if the availability of firearms reflects the political views of a population, and if the availability of firearms is related to the suicide rate, then it is possible to find statistical correlations among the three, without implying that a particular political view is suicidal or causes suicide any more than suicide causes a political view.

The study by researchers at the University of California, Riverside presented the following map of suicide rates by state:

Suicide_2000_2006

The map seems to show higher rates in states where one might expect more gun ownership, but, being a data person, I did a little experiment of my own.

I ran a couple of regressions, down and dirty, not up to publishable, academic standards. I used MS Excel, probably acceptable for this purpose but not a tool I would use for a publishable regression analysis.

My data sets were gun ownership from the Behavioral Risk Factor Surveillance System for 2001 and Median Income from the US Census Bureau for 2006. First, regressing gun ownership by state on income found that income was a significant factor, inversely related to gun ownership, and explaining 35 percent of the unexplained variation. This is not surprising as rural states are generally poorer and are more likely to have traditions of gun ownership for protection as well as for hunting.

It also meant that the cross correlation of income and firearms ownership might cloud the findings when I looked at the suicide rate from the latest CDC report and its separate relationships to the two factors. Those figures were for only 39 states, so that is how I handled it. My informal findings were that gun ownership rates were strongly correlated with the suicide rate, p=.00025 with R squared =.308, accounting for 30.8% of the unexplained variation. Income was inversely related to suicide and was much weaker, with p=.045 and R squared = .104.

Now, you might say, “Oh, suicide is related to economic factors. With recent economic challenges, of course suicide is rising.” You would be correct. Researchers from Rutgers have provided a graph of the relationship between suicide and unemployment.

Suicide and Unemployment
Source: Social Fact: The Great Depressions?

That is not, however, the public health issue, as there will always be stressors causing suicide. We need to find a way to block access to guns in the same way that we block access to bridges for suicidal people. Of course, there are a lot more guns than bridges. In the United States we ban automatic weapons from private ownership, so the issue is not whether the right to bear arms can be restricted: the entire debate is how extensive those restrictions should or should not be. The data on suicide suggests that greater restrictions on access would have a positive public health impact.

Violence Prevention and Mental Health

Posted by on January 24, 2013 Comments Off on Violence Prevention and Mental Health

The White House plan to reduce gun violence has substantial mental health provisions:

Children and Young Adults

  1. Project AWARE (Advancing Wellness and Resilience in Education) directed at students in schools
    • Mental health “first aid” training for teachers
    • Referral services for students
  2. Support individuals 16 to 25 outside of and beyond school
  3. School-based violence prevention, including mental health services for trauma and anxiety
  4. Train 5,000 mental health professionals to serve in the schools
  5. Initiate a national conversation to address stigma associated with mental illness

Ensure Mental Health Coverage

  1. Issue final regulations on private health insurance coverage of mental health treatment
  2. Ensure that Medicaid programs are meeting mental health parity requirements

In addition:

  • The $150 million Comprehensive School Safety program will help finance new school resource officers (police) or mental health professionals (psychologists, social workers, counselors).
  • The hiring decisions will be with local school districts.

My Take (this is a blog, isn’t it?)

  1. The problem of obtaining adequate mental health coverage for anyone is a major challenge because:
    1. There is neither a test nor a cure for mental illness, which means that diagnosis is expensive and difficult, and management is expensive and difficult
    2. Mental illness resembles a chronic illness with transitory remission, so there is a temptation to halt treatment during remission and hoard resources to deal with crises.
    3. Nearly all families and individuals, save the super wealthy (think $1 million in annual income), have insufficient resources to address the full spectrum of mental illness symptoms, some of which require residential treatment for long period to be optimally addressed
  2. Large segments of the population continue to provide moral diagnoses rather than accepting a medical diagnosis of mental illness
    1. Depressed people are seen as lazy and unmotivated; bipolar people are seen as lacking discipline
    2. The symptoms are largely invisible and intermittent–mental illness is only partially and rarely someone walking down he street talking to imaginary people.
    3. Consequently, a large part of the public is unwilling to finance the treatment of those seen as slackers.

    Bottom line: the Administration is to be commended for first steps, but any reasonable approach will require billions not millions of dollars

Policy, Politics, and Guns. Oh my!

Posted by on January 7, 2013 Comments Off on Policy, Politics, and Guns. Oh my!

No solutions here. Just some clarifications of a complicated subject.

1. While we have a constitutional right to “bear arms,” there is no obligation to do so.

Some people need guns. Most of us don’t. If you are a hunter (and not a bow hunter), you need a rifle or shotgun when you are hunting, but you can lock it up soundly the rest of the time.

For most people the use of a gun for self-defense is illusory—you aren’t going to get to the gun before someone gets to you.

Criminals often get guns by stealing them from licensed owners—so your gun is making lots of people unsafe.

Your gun is much more likely to be used for a suicide or discharged accidentally than for self-protection.

2. The constitutional right is not unlimited. The First Amendment is not unlimited: child pornography is not protected speech. The Second Amendment is not unlimited.

    a. There are prohibitions on owning automatic weapons and sawed-off shotguns.

    b. There is no protection for magazines with 30 rounds.

    c. The recent Heller case establishing a personal right was a 5-4 decision. Such decisions are often reversed when there is an absence of a national consensus.

3. There is no historical evidence that personally-owned guns have maintained freedom. There is clear evidence that they are the source of death from homicides, suicides, and accidents.

If we take a fantasy trip to an authoritarian United States of the future—several lifetimes from now, we will find that the U.S. military outguns any opposition, so in that fantasy world, only defections with weapons would have any impact on regime change.

In the present, civilian weapons are used to kill other civilians.

4. Personal automobiles are no more likely to be taken away than firearms, yet vehicles are registered, require proof of proficiency to operate, and require liability insurance.

The idea that anyone is taking away the firearms of the US civilian population is an excellent marketing ploy that has been successfully implemented several times in the past half century: someone suggests that there will be gun control as a first step to confiscation, and gun owners rush to the store to get more.

I do not claim to have answers to the problem of more than 30 thousand deaths from firearms annually.

However, I assert that in a democratic society we have the means to address the problem—and the obligation. We can do so with minimal inconvenience to anyone who wishes to legally own a firearm for hunting, target-shooting, or self-defense, while making it prohibitively inconvenient for individuals who wish to shoot school children.

Firearm Trends Leave Me Clueless

Posted by on January 4, 2013 Comments Off on Firearm Trends Leave Me Clueless

One of the more interesting aspects of firearm mortality is the trend over the past 15-20 years. Beginning in 1994 the rate of mortality began to drop. That was the year that the assault weapon ban passed. Note that the rate of firearm deaths was close to the rate for deaths in motor vehicle accidents.

Injury Deaths 1979_2007

The rate of firearm deaths dropped from 1993 to 1999 and has remained level since then. The rate of death from motor vehicle accidents has dropped, but not as steeply.

The rate of death from poisonings has nearly tripled. What is that all about?

It might be thought that the assault weapons ban brought down the death rate, but that is not likely. The chart below compares 1993 to 2004, showing that the rate for suicide with firearms dropped about the same as the rate for homicides. I may be mistaken, but assault weapons are not the weapon of choice for suicide. Something else must have been happening in those ten years, or until 1999, at least. I don’t know what it was, but it would be nice to replicate it.

Firearms 1993_2004

When events like the Newtown massacre dominate the airwaves, we would like to act to prevent the next one. I think we should act to prevent the next one. However, the data demonstrate how difficult it is to decide what will work. An effective policy does not have to solve the problem by ending all future incidents: it just has to demonstrate a substantial change in a positive direction. That will be challenge enough.

I really don’t want to write about guns . . .

Posted by on December 27, 2012 Comments Off on I really don’t want to write about guns . . .

Everyone has opinions on the subject, and few are indifferent.

The opinions are strongly held, not preferences. And everyone has recited the top 5 arguments for or against societal action, according to one’s opinion.

But how can anyone seriously write about health care in the United States without considering the impact of firearms?

I know that I am not interested in becoming one more activist in the debate—there are plenty of those on both sides. I also know that no opinion on any subject is without dissenters, including whether the sun will rise tomorrow morning.

Knowing that, I plan to point out some facts that might be generally agreed upon, no matter where one’s opinions lie.

First, firearm deaths are a public health concern. In 2010 there were 2,468,435 deaths in the United States from all causes, of which 31,328 were related to firearms. Deaths from firearms were 1.27 percent of all deaths, or one of every 78.8 deaths.

For purposes of comparison, there were 35,332 deaths from motor vehicle accidents that year, or 1.43 percent of all deaths, and one out of every 69.9 deaths. Source: National Vital Statistics Report, October 12, 2012, Centers for Disease Control and Prevention

Second, while the rate of death from firearms has been steady for the past ten or more years at about 10.2 per 100,000 of population, it is not equally distributed among age groups.

The risk of homicide by firearm is greatest between ages 18 and 44, while the risk of suicide rises with age through life.

Firearm Deaths by age and intent, 2001-2009

More to follow, reluctantly.