July 20, 2016

July 18, 2016

My reading of an outstanding “biography of cancer” titled The Emperor of all Maladies by Siddhartha Mukherjee has stimulated a line of thinking that I am finding to be very mind-opening.

Put simply, I believe we should re-frame and attack the issue of the enormous number of gun caused deaths in our nation as an issue of PUBLIC HEALTH. 
One thing guns, cancer, tobacco and automobiles have in common is their association with high rates of mortality, actual and potential.  And with their association with morbidity, automobiles, guns and tobacco have, to different degrees and at different points in time, raised the question of how “causal” the relationship is.
The struggle, or more precisely the “fight” (for indeed industry did fight) against the ever more evident and deadly linkage between cigarette and cigar smoking and cancer was brutal.  I won’t try to tell that chilling story here.  It’s done brilliantly in the aforementioned book. 
Cigarette smoking skyrocketed during the first half of the 20th century.  In 1870, the per capita consumption of cigarettes in America was less than one cigarette per year.  By 1953, the average adult American was smoking ten cigarettes every day.  (Sadly, as we went into the 1960s, I was smoking at four times that level!)  Not surprisingly, in this same period—the 1950s—a meteoric increase in lung cancer was being observed in the U.K. and the United States.  But was it being caused by the increase in cigarette smoking?  At first, that notion was greeted with more than skepticism. It was disbelief.  One evidence of this: even medical journals were routinely carrying cigarette advertisements.  At the annual conferences of the American Medical Association in the early 1950s, cigarettes were distributed free of charge to doctors who lined up outside the tobacco booths.  When I joined Procter & Gamble in 1963, there was an ashtray placed in front of every member of the Executive Committee, with no thought it was carrying a danger (though by then research was amply available to demonstrate that).  Almost everyone smoked, many nonstop. 
Ironically but profoundly, and this has great significance to the issue we face on the causal relationship of the availability of guns to increased morbidity,  as Mukherjee writes, it was the “rapid, viral ascendency of tobacco that made its medical hazards virtually invisible.”  He points out that our intuitive appreciation of statistical correlations “performs best at the margins.”  When rare events are superposed against rare events, the association between them can be striking.  That had been seen in drawing a link between scrotal cancer and chimney sweeping in the U.K. Both the profession and the disease were uncommon enough that the juxtaposition of the two stood out starkly like a lunar eclipse; two unusual occurrences in precise overlap.
However, as cigarette consumption escalated into a national addiction, and the documented incidence of cancer also sky rocketed,  it became harder to discern an association  of smoking with cancer. 
Similarly, with guns today, with their penetration growing at a rate which like cigarettes in the past can only be described as an “addiction”—over 300 million in homes in the United States, twice the level of 1968—and, sadly, with deaths involving guns also becoming more prevalent day to day, it becomes harder to make direct associations.
In time (measured in decades)  and with great difficulty, the causal relationship of cancer and smoking, was irrefutably established.  It happened only thanks to the perseverance and courage of scientists and academics.  Prospective trials were carried out among (ironically, at first doctors) matching those who smoked and those who didn’t and then documenting the prevalence of lung cancer over many years. The results were unarguable. But even then getting clear warnings on packages and banning televison advertising was resisted by the industry-- and by legislators committed to the industry, just as is the case today with guns.   It took decades to bring regulations which recognized and grew from the knowledge that cigarette smoking is a “public health issue” of the highest magnitude. And it came through the Public Health Administration, not Congress which was beholden to special interests just as  is the influence of the NRA on legislators today.  

I do not believe the type of "prospective", irrefutable research has been carried out to establish the causal relationship of guns and various forms of deaths caused by guns that would match the research which eventually underpinned the causal relationship of cigarette smoking and cancer.  It would be very hard to model that. 

But there is powerful "retrospective" and "associative" evidence to show the correlation between gun penetration and deaths caused by fire arms. The facts are staggering. Based on 2010 research reported in the Journal of American Medicine, deaths caused by fire arms are (per 100,000):

U.S. 10.2
Canada 2.3
France 2.8
Germany 1.1
UK 0.2

Gun penetration per 100 people:

U.S. 112.6
Germany 30
UK 6.6
Russia  8.9

The instant death which a gun can cause in a domestic dispute or suicide attempt (compared to other "weapons") makes it altogether more lethal just by the very fact that it is on hand. Just being there is a "public health" risk of a greater dimension than alternative implements which can cause great injury and even death.
Today, no one who can read can mistake the danger that they are embarked on in smoking.  This is not being done with the usage of guns.

So what about automobiles?  How do they come into the picture?

On a per capita basis, automobiles used to place far higher in the ranking of the causes of death (and injuries) in this country than they do today.  In this case, it was easy to establish the causal relationship.  There was no mistaking that, when a car crashed and there were no seatbelts, and the passengers flew through the windshield and died, that the cause of death was irrevocably related to the car accident.  And in time, for this and other reasons, sharp regulations have been brought to driving a car.   You need to have a license and you have to have that license renewed regularly.   You have to pass a driver’s test to show that you know what you’re doing when you drive the car.  Surely we should insist on nothing less than that when one buys a gun.  We don’t insist on that today.  I can find no logical explanation for that.
Many will raise the familiar argument that guns don’t cause death, people do. It is their choice.  Of course, that could have been said about tobacco—and it indeed was, literally, vehemently, repeatedly.  It wasn’t the tobacco that caused cancer, it was the smoker.  And it could be said about automobiles, too.  It wasn’t the car; it was the driver or the weather or the road.  Yes, but…we have identified a causal relationship of such importance that we ought to be certain that proper steps are being taken to regulate its use so that not only harm to the “owner” but harm to others who are not the owner can be constrained.  That is certainly the case with guns.  Sometimes, it is the harm to the “owner” in the case of accidentally shooting oneself and suicides, which happen all too often.  But even more, it is the danger to people who don’t “own” the gun.  To not require a license and training on how to use the gun is absolutely irresponsible. 
Which brings me to my last point where the relationship of tobacco and cancer, and of automobiles and guns, has something to teach.  It come under the heading of prevention.  It was decades before the medical community was prepared to really address the issue of “prevention” when it comes to cancer.  There were those who favored surgery; others, oncology; of course, many, both. But it was only later, and it’s still a movement underway, that the issue of “prevention” in terms of diet and living habits, especially smoking and alcohol,  as they relate to the risk of cancer was addressed.  It manifested itself especially in the focus on not smoking, and this has had a major effect in reducing lung cancer. 
“Prevention” has played a big role in the reduction of deaths through automobile accidents too.  The requirement for seatbelts, speed limits (no matter how inadequately enforced) and other safety devices, have all come into play, under the mantra of “public health”.
I don’t think we have thought deeply enough, or taken action, on what can be done to prevent needless deaths from widespread gun ownership much as we have done on smoking and driving a car.
There will be many, certainly the NRA, that retreat to the familiar citation of the “rights” conferred by the 2nd Amendment.  This argument should carry no weight when it comes to making intelligent modifications on the requirement for gun ownership dictated by learnings from history.  Certainly, the authors of the 2nd Amendment did not contemplate that it would confer the right to have semi-automatic and automatic military-style weapons in the hands of millions of people; weapons capable of killing dozens and dozens of people in a matter of seconds.  Just as with automobiles, or now with tobacco, I cannot believe the authors of this Amendment would object to there being strict rules dictated by the well documented knowledge  of the risks these guns pose to public health and life which would  require clearance and registration before they could be purchased and training before they could be used to be as sure as we could that they were going into responsible hands that are capable of resposnsible use.   
This is a short treatment of a complicated subject.  I hope it sheds a light on what it took to understand, document and then control the causal impact of cigarette smoking on cancer and the impact of automobiles on highway deaths in a way that provides insight on what we should do about the tragic loss of life from the broad and inadequately regulated penetration of guns in this country today. Put simply, I believe we need to frame and approach this as a "public health" issue, which it surely is. 

1 comment:

  1. As always a sharp observation and concise translation into a nice argument for change. Thanks.