Bioethics Forum Essay
Treating Gun Violence as a Public Health Threat: Not Exactly What We Meant
This week, the United States saw two momentous public health events. The first was the official recording of one million deaths attributed to Covid. The second was the 198th mass shooting of the year, in Buffalo, N.Y., by an 18-year-old white male.
Both the pandemic and gun shootings are threats to public health. Individual approaches to these problems are unlikely to be effective for very long. Many writers, including myself, have suggested that the answer to gun violence is to take a public health approach.
I raised this issue, in large part, because I had cause this week to review an article that I wrote after the 2012 Sandy Hook school shooting, in which 20-year-old Adam Lanza shot and killed 26 people, including his mother, and then killed himself. Like many writers and organizations, I considered mass gun shootings as a public health threat. However, a recent reading of my 10-year-old essay stopped me short:
“If there were an infectious disease that could be prevented with a side-effect-free vaccine, we would look askance at anyone who did not get the inoculation. In fact, if that disease could lead to the death of other people, then under public health law, one might be required to be vaccinated.”
I could not have been more wrong.
The idea of gun violence as public health threat or an epidemic has a different meaning today than it did in 2012, since we are in the third year of a viral pandemic. As I write, the U.S. faces another surge of Covid cases. With one million recorded deaths, only 77.7% of Americans have gotten a single dose of a Covid vaccine, in a time when fourth shots are recommended for many. Only two-thirds (66.5%) of us are fully vaccinated, fewer than half have received their first booster (46.4%). Whether we look askance at anyone who did not get vaccinated depends on our politics: liberals and Democrats are likely to see this as irresponsible whereas conservatives and Republicans are more likely to see refusal to be vaccinated as an exercise of freedom.
Last month, the 9th Circuit Court of Appeals—known as the most liberal court—turned down a mandate for prison staff in California to be vaccinated against Covid. New York City reached a high-alert level of Covid transmission this week and yet is only recommending indoor mask wearing instead of mandating it, which was the response earlier in the pandemic.
The reality is that we have treated gun violence as a viral pandemic. But rather than coming together as a nation and using the power of government to protect the public’s health, which is what I had thought would happen in a disease outbreak, we have treated Covid-19 the same way we treat gun violence—with thoughts and prayers.
Public health in the U.S. has been severely broken in the 21st century through funding cuts, workplace violence and threats against public health workers, and the politicization of collective action. Efforts to combat the Covid pandemic and gun violence have been anemic. The result is an “on our own” approach. People are left to decide for themselves which precautions to take, if any, against Covid. And it is up to individuals to protect themselves against gun violence. Children participate in active shooter drills, and bulletproof backpacks are part of back-to-school shopping. In both cases, rather than taking an upstream, public health approach, the U.S. puts the burden on the individual, which usually means that the most vulnerable (children, immunocompromised, lower socioeconomic status, disabled, elderly) are sacrificed.
The call for treating gun violence as a public health issue has been answered, just not in the way anyone suspected or hoped that it would be.
Craig Klugman, PhD, is the Vincent de Paul Professor of Bioethics and Health Humanities at DePaul University. @CraigKlugman
Excellent, if depressing, piece, Craig. Now, what can we do to restore public health? How can we become more like Australia?
I submitted a reply with notes on what needs done to ‘restore public health’ but Hastings hasn’t published it.
In summary: distrust has been/is destructive of public health. Broad and deep attention must be paid to restoring trustworthiness in public health’s systems and agencies, experts and messaging, aims and intentions.
Australia? You might be onto something. Reporting is that Australia and New Zealand show high levels of public trust in public health through the pandemic: https://www.theguardian.com/world/2021/nov/29/trust-in-scientists-soared-in-australia-and-new-zealand-during-covid-pandemic-poll-finds But how are Australia and the USA different?: one site tells us that Americans get divorced a lot more, drink a lot more soft drinks, and ride roller coasters a lot more than Australians; that there is much more ‘red tape’ to start a business in the US, and that preparing income taxes takes a lot more time. etc etc etc.
But, what about healthcare? Commonwealth Fund 2021 report tells us The top-performing countries overall are Norway, the Netherlands, and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.” So, apparently, something desperately is wrong with how Americans have dealt with access, efficiency, and equity in health care. Surely, these facts on the ground are associated with distrust on the ground.
Where I live, in rural Virginia, south of the James River – a vast set of regions, from the Appalachia mountain region (former, and still current, coal mining region) to the Piedmont (former tobacco, and now more general agricultural region including a lot of forestry), with many depopulating counties and boarded up factories and storefronts and other signs of disinvestment and despair – why should anyone ‘trust’ federal, or state, government – including public health systems and agencies? It has been clear, across generations, that policy experts, academic researchers and teachers, and economic and cultural elites have not been concerned with access, efficiency or equity of our health care. Each year we learn again from County Health Rankings data (this year’s datasets are exceptionally granular and informative regarding rural county/metro county comparisons) – but already knew – that rural Virginians get sick more, stay sick longer, and die sooner than the ‘average’ Virginian, and that the divide is even more obvious when comparing out counties to the metro – urban and suburban – counties north of the James River. Examining the rural-urban divide in most states may reveal similar patterns: poor rural access, inequitable rural outcomes, unjust burdens on rural communities.
Rebuilding trustworthy health care and public health systems, agencies, and leadership must be a high(est) priority for public health going forward.
Start with remedying the poor access, inequitable outcomes, and unjust burdens endured now for generations in rural communities, which are disproportionately harmful to communities of color. In the American South many/most rural or very counties are disproportionately Black and/or multiracial. Throughout the midwestern states local rural communities are increasingly Latinx/Hispanic. And most Tribal communities through the US are rural or very rural. Gain their trust in public health, across rural America.
Does your university or think tank – wherever it is – include rural health in your teaching, training, and research? Do your public health assessments, analyses and strategic plans include rural places, that have historically provided, and continue to provide, the food you need, the energy you need, clean water resources, clean air, carbon sequestration,…. and that are places where many/most US metros export/dump massive mountains of waste (household waste, toxic waste, radioactive waste, medical waste, polluting waste, etc)? And do your social justice and environmental justice and reparations discussions include that waste? or the ‘cheap labor’ historically and currently provided by rural working classes – from earlier economic and legal policies of enslaved or indentured labor, through to current economic and legal policies of ‘rural sacrifice zones’, ‘rural extraction and disinvestment’, and ‘globalized labor markets’ – that ‘experts’ determined were necessary for cities to grow and thrive?
Trust-building may start with the truth-telling of hearing and responding to difficult questions.