Gun Violence - A Call For Physician Activism:
Lessons From The
Struggle to Ban Weapons of Mass Destruction Robert
C. Wesley, Jr., MD* and Victor W. Sidel, MD** *
At the time of publication RCW was Director of Clinical Electrophysiology, Long
Beach VA Medical Center, Long Beach, CA, and Assistant Professor of Medicine,
University of California-lrvine, Orange, CA USA; ** VWS was Distinguished University
Professor of Social Medicine, Montefiore Medical Center, Albert Einstein College
of Medicine, Bronx, New York USA. Copyright 1994
Medicine and Global Survival Abstract The
proliferation of firearms in the United States, including handguns and semiautomatic
weapons, has contributed to a steep increase in gun-related homicides, suicides,
accidental deaths, and injuries. The campaigns organized by physicians starting
in the 1960s to educate the public about the nature and consequences of nuclear
weapons and other weapons of mass destruction provide a model for those concerned
today with the epidemic of gun violence. A new physicians campaign would call
for the elimination of the most lethal weapons from civilian hands; a ban on the
most lethal forms of ammunition; and stricter governmental regulation of the ownership
and use of all firearms. [M&GS 1994;1:67-73]
Guns, Guns, Guns On February 9,1993, a lone gunman carrying
an arsenal of concealed weapons severely wounded three physicians in the walk-in
emergency area of the County-University of Southern California (USC) Medical Center.
The sudden, inexplicable ferocity of such a crime would have shocked the U.S.
public sensibility 30 years ago. Now it is merely a footnote in the swelling tide
of communal violence that increasingly engulfs U.S. society. While there are multiple
factors that contribute to this level of violence, one factor seems to us foremost;
the unrestricted proliferation of firearms. Left unchecked, this proliferation
has created conditions that lead to mass destruction. The extent of the
proliferation is evident in the wrenching details of every evening newscast. At
present, there are approximately 200 million firearms in the United States, of
which more than 60 million are handguns [1,2]. The precipitous rise in handgun
availability became evident in the mid-1960s when the number available for sale
increased by 50% in just one year [1]. As the number of firearms has risen (Fig
1), so has the associated carnage. Between 1950 and 1980, the number of annual
firearm-related deaths per base population in the U.S. increased by nearly 250%
[3]. By 1980, nearly 60% of all homicides and suicides were caused by firearms
[3]. Homicide The paroxysm of violence in our society
continues unabated. The number of murders in America increased from below 20,000
in 1987 to more than 23,000 in 1990 [2]. Homicide is the fourth leading cause
of premature mortality in the U.S., the third leading cause of death among all
youth aged 15 to 24 years, and the leading cause of death among African American
men aged 15 to 34 years [4]. The evidence that firearms are a major factor is
substantial. The incidence of murders by means other than firearms increased substantially
between 1960 and 1980; however, this rate of increase was only half of that associated
with firearms [5]. Most disturbing has been the recent substantial rise in firearm
homicide victims among children five to nine years of age [6]. An even greater
impact of gun violence on total mortality has been noted among older children.
Between 1985 and 1990, firearm-related homicide increased by 141% among teenagers
15 to 19 years of age [7]. By 1990, 82% of homicides among teenagers 15 to 19
years of age were associated with firearms [8]. Six hundred fifty thousand times
a year, handguns are used in attempted rapes, robberies, and assaults, resulting
in 90,000 injuries [2]. In Los Angeles County alone, in the year before the riots
(1991), more than 8,000 people were either killed or wounded by firearms [1].
Suicide The link between firearms and suicide is
well established. More people kill themselves by firearms than all other methods
combined [3]. The key factor appears to be the finality that pulling a trigger
conveys. Few recover from a firearm-related attempt (Fig 2) [9,10]. The presence
of firearms in the home, irrespective of type or method of storage, is the most
strongly associated factor in successful suicide attempts among adults as well
as emotionally disturbed adolescents [10,11]. Injury Related
to Access The accessibility of firearms appears to be a key factor in the
likelihood of an injurious encounter. Even though the incidence of assault is
comparable for Denmark and the communities of northeastern Ohio, the homicide
rate in Denmark is one-fifth that of northern Ohio [l2]. In Denmark, private ownership
of firearms is permitted only for hunting, and handguns are rigidly restricted.
Sloan et al. compared two demographically similar communities (Seattle and Vancouver)
with differing prevalences of hand gun availability [5]. Seattle, the city with
the greater prevalence of handguns, experienced a nearly five times greater rate
of handgun homicide even though the rates of assault in Seattle and Vancouver
were similar [5]. Several additional studies have suggested that firearm-related
deaths are high in regions where firearms are readily available [13,14].
More recent studies have focused specifically on the relationship between firearms
and the perpetration of homicide within the home. When assaults occur between
family members and intimate acquaintances, the victim is 12 times more likely
to die if the assailant utilizes a gun [15]. The presence of a gun in the home
is an independent risk factor for familial homicide and a powerful predictor when
coupled to prior histories of drug abuse or physical assault, or both [16].
Although there are data to suggest that a gun may provide protection in self-defense
when reached and used in time, the strength of such data is grossly overstated
[17,18]. Anecdotes of successful self-defense must be weighed against examples
of egregious misuse, such as the slaying of Yoshiro Hattori, a camera carrying
Japanese exchange student, fatally shot when mistaken for an armed intruder [19].
When guns are viewed as a risk factor for violent death and injury, it is clear
that gun tragedies far outweigh the benefit of self-protection. The
Link to Arms Control Much has been written about violence as a public health
problem and about the responsibility of physicians to work for gun control. But
these analyses have failed to examine an analogous effort of physicians in the
arena of arms control. Indeed, the role that physicians might play in the containment
and elimination of firearm-related communal violence is suggested by the vital
role assumed by physicians in reducing the threat of global devastation by weapons
of mass destruction. In 1962, a series of sentinel articles described in rigorous
detail the virtually unimaginable medical and public health consequences of thermonuclear
war [20-23]. An accompanying editorial clearly stated the rationale for physician
activism: "No single group is as deeply involved in and committed to the survival
of mankind. No group is as accustomed to the labor of applying the practical solutions
to life-threatening difficulties" [24]. The authors of the articles were
leaders in the founding of Physicians for Social Responsibility (PSR). At that
time, the demonstration of iodine-131 (a potential sequestrant in juvenile thyroid
glands) in the food chain and of strontium-90 in the deciduous teeth of children
was potent evidence of the hazards of above ground nuclear testing. The intellectual
and moral arguments of physicians coupled to these data helped to galvanize public
support for the Limited Test Ban Treaty signed by President Kennedy and Premier
Khrushchev in 1963, which banned nuclear tests in the atmosphere, in space, and
underwater. The Antinuclear Campaign The years that
followed were characterized by a widening and deepening of physician commitment.
In 1966, the concern over the nuclear threat expanded to encompass the dangers
of chemical and biological weapons [25]. During this period, the ethical imperative
for physician opposition to weapons of mass destruction continued to crystallize
[26]. The principle that "prevention is the only way to reduce mortality where
treatment is ineffective" was specifically examined in relation to the prevention
of nuclear war [27]. An analysis recalled the wisdom and courage of the 19th century
English anesthesiologist John Snow, who, in the 1850s, linked the spread of cholera
to contaminated water supplies [27]. Dr. Snow worked successfully to have the
pump handle removed from a communal well and opposed the practices of a private
water company, at the time decidedly political acts [28]. The late 1970s
and early 1980s saw the development of new and massively destructive multiwarhead
missiles, their widespread deployment, and increasingly belligerent positions
on both sides of the cold war. The physician movement responded with a new sense
of urgency [29-33]. With less sympathetic political leadership in power, physicians
took their case for the containment of weaponry directly to the public, in the
U.S. and abroad [29-33]. These efforts were effective in creating a climate for
political dialogue, which in turn led to unilateral actions to reduce the threat
and to multilateral actions through diplomatic compromise. The Nobel Committee
recognized this contribution by awarding the 1985 Peace Prize to the International
Physicians for the Prevention of Nuclear War (IPPNW), an organization with affiliates
in 80 nations largely modeled after PSR. Both physician organizations have played
important roles in support of international treaties banning biological weapons
(the Biological Weapons Convention, 1972) and chemical weapons (the Chemical Weapons
Convention, 1992). Elements of Symmetry The analogy
between an established role for physicians in the struggle for a global ban on
weapons of mass destruction and a potential role for physicians in containing
the ever growing threat of firearm related violence is striking (Fig 3). Both
problems have been characterized by technological innovations of grotesque lethality.
With regard to the global threat, we have observed the development of multiwarhead
land- and sea-based strategic nuclear weapons, the cruise missile, and devastating
conventional weapons such as fuel-air explosives [34]. With regard to the communal
threat, we have seen the development of semi-automatic assault pistols such as
the MAC-11 (9mm, 12.5 inches, 32 rounds), the UZI (9mm, 9.5 inches, 25 rounds),
the TEC-9 (9mm, 12.5 inches, 36 rounds), and the Calico MlOOP (9mm, 17 inches,
100 rounds) (Fig 4) [35]. A horrifying "innovation" has been the Street Sweeper,
a 12 gauge shotgun with a revolving cylinder capable of firing 12 rounds [29].
The foreign version, previously used by South African security personnel, failed
to meet the sporting-use test and was banned for importation [35]. However, domestically
produced versions of the firearms mentioned above are not subject to this standard.
Each problem is also characterized by massive deployments. During the
1980s, the United States added to its arsenal: 100 B-lB bombers; 1,600 air launched
cruise missiles; nine Trident submarines, each carrying 16 missiles with 12 warheads
on each missile; and 50 MX missiles carrying more than 400 warheads; as well as
other weapons [36]. By 1990, the United States and the Soviet Union had more than
12,000 and 11,000 strategic nuclear warheads, respectively. The world's nuclear
arsenals contain the equivalent of three tons of TNT equivalent for every human
being on the planet. In America, firearms are characterized by a similar
proliferation. At present, there are nearly a quarter of a million federally licensed
firearm dealers operating in the United States under limited supervision [1].
Despite ordinances to the contrary, guns frequently find their way into the hands
of children and adolescents. A survey of teenagers revealed that 41% of boys and
21% of girls claimed they could easily obtain a handgun if they so desired [1].
Nearly 2 million guns are sold each year. Most disturbing is the proliferation
of highly lethal and concealable and potentially alterable semi-automatic and
assault weapons. The number of such weapons in civilian hands is conservatively
estimated to be in the hundreds of thousands [35]. Finally, adequate solutions
to each problem have been blocked by the existence of rigidly ideological positions,
which have served vested economic interests, possessing inordinate political influence
[36,37]. Both problems have also been maintained by misguided and dangerous beliefs
that security, whether personal or national, lies in the possession of devastating
weaponry. In America, this latter consideration appears to be based on the seemingly
visceral fear that the government would devolve into tyranny were it not held
in check by an armed citizenry. This notion parallels sentiments upholding the
rights of sovereign nations to possess and control weapons of mass destruction
in opposition to international authority. The Physician
Role The idea of the physician's role in a ban on firearms is not a new
one [2,6,38-43]. Coincident with the emotional upheaval surrounding the King and
Kennedy assassinations of 1968, an insightful editorial asked, "Can the voice
of the medical profession not be heard above that of the lobbyists representing
gun clubs and other groups, and usually blamed for congressional activity in this
area?" [38] The editorial further insisted that "the sale and traffic of firearms
must be controlled..." Medical associations such as the American Academy of Pediatrics,
the American Public Health Association, and the American Psychiatric Association
have formally endorsed a proposed ban on handguns, and others such as the American
Medical Association and the National Medical Association have highlighted the
need for greater physician action [2,6,39,41,44]. The proliferation of firearms
is clearly a major public health and medical problem [45,46]. Where do we go from
here? Reshaping Public Debate Although the nuclear
threat remains, the work of PSR and IPPNW has raised the moral conscience of the
world against the use and proliferation of weapons of mass destruction. Just as
physicians have helped to change public perceptions of the global arms race, so
must we now help to reshape the public debate regarding firearms to reflect their
growing lethality (Fig 5). Our profession must take the lead in challenging erroneous
interpretations of rights granted under the Second Amendment, the legalistic justification
for today's carnage. We must vigorously point out that the Supreme Court has upheld
a collective, not a personal, right to bear arms; and that the Amendment's key
qualifying phrase granting such rights to "a well-regulated militia" has been
conveniently ignored (Fig 6) [47-49]. We must remind our citizenry that the Supreme
Court has allowed to stand the ruling of a lower court upholding a 1981 ban on
handgun sale and possession in Morton Grove, Illinois [44]. Physicians must influence
the societal view of guns and gun violence, as we are doing in similar campaigns
against cigarette smoking and drunk driving. In America, guns, unlike
consumer products, are not subjected to federal safety standards. Guns must be
treated like all other products that can maim and kill. Let us never minimize
that maiming and killing are the results of their use. Again as before, the overriding
principle of prevention must prevail. The production of guns must be curtailed;
their lethality reduced; and their possession strictly and assiduously regulated.
The force of the medical profession through endorsements of all its constituent
bodies must be placed behind these general principles. Endorsements alone are
not enough. If there is one clear lesson that can be gained from the struggle
for global arms control, it is that there is no substitute for direct education
and mobilization of the public. It is indeed the mandate that echoes to us from
25 years ago: "Such pronunciamentos satisfy many but persuade few. It is the individual
physician who as a citizen must take the time to act" [38]. Initial
Goals of a Physician Campaign What then should be the initial aims of a
physician led campaign? 1. We propose the immediate and complete elimination
from civilian hands of the most lethal weapons confronting society: a ban on further
sales combined with confiscation of automatic and semi automatic assault rifles
and pistols in addition to maintenance of the current bans on importation and
future production. Such a proposal would be parallel to international efforts
to control the most lethal nuclear weapon delivery systems; i.e., multi-warhead
missiles. Legislation passed by the U.S. House in May, prohibiting the manufacture
and sale of certain types of semiautomatic assault weapons, is a step in the right
direction. The political margin of victory for this bill was so narrow, however,
that stronger measures may be difficult to pass unless the public is better educated
and more vocal in its support of gun control. Moreover, the bill does not retroactively
ban assault weapons that were purchased legally before its passage, or that will
continue to be purchased legally before it is signed by the President.
2. We further advocate a total ban on the most lethal types of ammunition and
the tools of assassins: silencers and kits for silencer assembly. 3. While
the goal at present may seem elusive, no solution is adequate without the rigid
restriction of handguns. We must exact on ourselves the demonstrated standards
of more tranquil societies. All weapons must be registered and competency in safety
standards demonstrated as a condition of ownership. Concealment of weapons cannot
be tolerated. Long guns for legitimate, law-abiding purposes may remain in private
hands. However, handguns should not. Those who enjoy target shooting may sequester
handguns in secure, public firing ranges. But the targeting of human beings must
stop. Conclusion -- A Call for Action Let us not
be deterred by opposition, nor deluded that such goals will be easily attained.
Many will proclaim an infringement of sovereignty. Again there are lessons from
the global struggle. Has not a proliferation in firearms fueled the internecine
conflict in Somalia, resulting in famine and societal dissolution? While the rights
of sovereignty might support their possession, no enlightened nation would find
desirable or wise the unbridled proliferation of weapons of mass destruction.
Is not the common good promoted by their restriction? In the past, the
call went forth for science regarding the nature of firearm injuries [43]. The
present contributions of the medical literature have more than exceeded such exhortation.
By all scientific and social measures, the damage to our society has exceeded
"the killing threshold," i.e., any conceivable standard for a civilized society
[2]. Now is the time for action. This action must not preclude or substitute
for other actions to reduce communal violence. Until the injustices of our society
begin to be effectively addressed, until effective remedies to eliminate poverty
are enacted, until the models for violence on television and motion pictures are
reduced, until all of us begin to deal with the root causes of violence in our
families and in our communities, gun control alone cannot solve the problem. But,
as in the prevention of catastrophe by weapons of mass destruction, the elimination
of the firearms is a good place to begin. Acknowledgments
We are indebted to Drs. H. Jack Geiger and Bernard Lown for their comments on
the manuscript and to Mrs. Lesley Anderson for her preparation of the manuscript.
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