Tuesday, January 15, 2013

Assault rifles, high capacity magazines, background checks and reverting to form

That is what it is coming down to according to the talking heads on the Sunday morning TV circuit this week.  Both the NRA and several politicians agree that there are not enough votes for an assault weapons ban.  There may be enough votes for a high capacity magazine ban but both sides acknowledge that these clips are inexpensive and there are already a lot of them out there.  The background checks issue is also debatable.  The NRA and the pro-gun factions are talking a lot about mental illness and needing to have a mechanism to prevent people with mental illnesses from getting guns.  There is minimal discussion of improved mental health services.  On CNN Sunday  morning there was acknowledgement that during tough budgetary times the line items supporting mental health treatment are the first to go.

So basically despite all of the hype about how the Sandy Hook incident was going to energize politicians to actually solve a problem – they appear to be rapidly reverting to form and not solving anything.  The NRA President seemed confident that nothing would happen (the NRA opposes any assault weapons ban or high capacity magazine ban), but cautioned that the President has a lot of political capital and might be able to influence the high capacity magazines.

I wanted to file this post tonight before the final recommendations of the Vice President because I think that there have been two recent articles in the medical literature that are very relevant. At the legislative level Jerome Kassirer, MD has a recent article in Archives of Internal Medicine. Dr. Kassirer is a former editor of the New England Journal of Medicine and I corresponded with him on this issue nearly 30 years ago.  He clearly has not lost interest over the years and brings several concepts into focus in his editorial. The first concerns the fundamentals of screening and how any effort to identify potential shooters would result in the false positives greatly outnumbering the true positives and how that renders screening impractical.  His primary focus has to do with countering political initiatives.  As an example the National Center for Injury Prevention and Control at the CDC is currently prevented from studying gun related injuries.  He advocates for countering that.  He advocates for a comprehensive analysis of gun ownership.  He also advocates for resistance to any laws that restrict physicians being able to talk about firearms with their patients. He wants to see universal background checks from gun purchases, gun safety devices including coded weapons, and restrictions on large capacity magazines and sales of large amounts of ammunition. His article refers to firearms as "Weapons of Mass Destruction".  Small arms and light weapons are in fact a major global problem.  This Federation of American Scientists primer highlights the issue and the fact that there have been over 1 million deaths due to small arms in the past decade. Some advocacy organizations estimate that as many as 250,000 people per year are killed by small arms fire worldwide.

The second very important article comes from the Journal of the American Medical Association. The authors of this article emphasize the public health approach to curbing gun violence. This is a very important concept that people have a difficult time grasping. Whenever I bring up the issue of psychiatrists being involved at the level of primary and secondary prevention most people distill that down to whether or not psychiatrists can predict violence.  A public health approach to violence prevention is much more comprehensive and multidimensional.  The authors give several good examples in this paper including modifying sociocultural norms.  They use the example of tobacco being media symbol of “modernity, autonomy, power, and sexuality" and how that was changed.  They suggest an analogous campaign to equate gun violence with weakness, irrationality, and cowardice. The article has a table that has 18 evidence-based public health interventions that have been successful in other areas that could be applied to gun violence.  This is actually the preferred strategy that I have been advocating for the past decade and the authors of this article state it very eloquently.

At this point in time it will be interesting to see if the Vice President's recommendations include any of the interventions suggested by these two articles or the recommendations from the APA.

George Dawson, MD, DFAPA

1: Kassirer JP. Weapons of Mass Destruction. Arch Intern Med. 2012 Dec 21:1-2.  doi: 10.1001/jamainternmed.2013.4026. [Epub ahead of print] PubMed PMID: 23262523.

2.  APA Recommendations to the Biden Task Force

3.  Mozaffarian D, Hemenway D, Ludwig DS. Curbing Gun Violence: Lessons From Public Health Successes. JAMA. 2013 Jan 7:1-2. doi: 10.1001/jama.2013.38. [Epub ahead of print] PubMed PMID: 23295618.

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