Yes, “Here we are again.” Drs. Malina, Morrissey, Campion, Hamel and Drazen, along with the editors of the New England Journal of Medicine, are frustrated. They explain themselves, though not the rest of us, in their editorial “Rooting Out Gun Violence” in the December 16 NEJM. Inexplicably, Americans have somehow resisted the call of the anti-gun confederacy to enact “essential regulatory changes”, such as prohibiting “people on the terrorist watch list from getting guns”, to “enhance background checks”, and to “ban … military-style assault weapons [sic], which ought to be uncontroversial”. One wonders whether they get any news apart from the front page of the New York Times.

“Here we are again. Less than a year ago, an editorial in the Journal by Kassirer reexamined the massive public health problem of gun violence in the United States, and a Perspective article by Sacks, born of a personal tragedy, lamented the defunding of research on firearm-injury prevention. Kassirer called for electing “lawmakers at all levels of government with the courage to defy gun lobbyists,” so that essential regulatory changes can finally be enacted — as physicians, public health experts, and others have been recommending for decades. But in early December, the day after a young couple turned up at a holiday party in San Bernardino, California, with semiautomatic weapons and went on a shooting rampage, killing 14 people and injuring 21, Congress voted down a measure that would have prevented people on the terrorist watch list from getting guns and stalled on a measure to enhance background checks. An existing federal ban on military-style assault weapons, which ought to be an uncontroversial, if inadequate, first step, was allowed to lapse in 2004.”

Let’s pause to mention that the “young couple … in San Bernardino, California … [who] went on a shooting rampage” were not on anyone’s radar and were not prohibited gun buyers in the National Instant Background Check System. They did not seem to care that they were violating many laws by making bombs, modifying rifles and conspiring to commit a terrorist act. They obviously cared only about killing and injuring 35 innocent people, with plans to cause even more mayhem and murder afterward. They were freely operating in the state with the most restrictive gun laws. And we already know the effects on ‘gun violence’ of the 10 year federal ban on assault weapons, which is now blessedly in the past: virtually nothing.

“In 2013, the latest year for which the Centers for Disease Control and Prevention (CDC) has data, more than 33,000 people in the United States died from gunshot injuries and more than 84,000 survived with such injuries, many of them requiring ongoing care for both physical and mental health. After this year’s high-profile events in San Bernardino, Colorado Springs, Charleston, and Roseburg, Oregon, commentators once again marveled at the vast gap between U.S. rates of gun deaths and those in other developed countries, which either have never witnessed the epidemic of gun violence and the kind of mass shootings that are now routine here or have acted effectively to stop them. If any other public health menace were consistently killing and maiming so many Americans, without research, recommendations, and action by the CDC, the public would be outraged.”

The 33,000 deaths from ‘gun violence’ comprise about 2/3 suicides, 1/3 homicides, and approximately 600 accidental shootings (less than 2% of vehicular accident deaths). The 84,000 injuries distribute with the majority surviving intentional and accidental shootings and the minority surviving firearms suicide attempts. These are all very different phenomena requiring very different interventions, with only one common factor: people misusing guns.

Epidemics present acutely and don’t steadily decline for years of their own accord, like gun deaths in the U.S. have for decades—in spite of even more rapidly increasing private gun ownership and concealed carrying of handguns (the type that is also most involved in crime). Some commentators marvel at how decreasing rates of violent (including gun) crime in the United States compare to rises in Great Britain and Australia after they banned most firearms.

Mass shootings, however defined, are certainly not “routine”. Emphasizing them distracts from the main problem. Most gun crime takes place in our inner cities, one on one, among gangs and drug culture, predominantly affecting minority Americans. “If any other public health menace were consistently killing and maiming so many Americans … the public would be outraged.” Hmmm … nearly 800,000 deaths and far more morbidity occur each year due to medical misdiagnosis, mistreatment and other mistakes. It is hard to perceive the mote in one’s own eye when gazing so fixedly at the distraction of other, lesser problems.

“But in the United States, the National Rifle Association (NRA), the legislators it has funded, and a certain breed of gun owners have stood in the way even of research to determine what policies might help. The single or double gun deaths that go on around us every day rarely evoke any public response, and the predictable reflex response to the louder mass shootings, after exhortations to pray for the victims, takes two forms: calls for reviving research and calls for improving mental health care.”

There is a “certain breed of gun owners” that opposes medical academics making hay out of the exploitative, widely marketed ‘public health’ model for defining and addressing the ‘gun violence epidemic’. The most serious public response, one that respects the rights and abilities of Americans, is by many sheriffs encouraging those who carry to be alert and ready to act as first responders to violent attacks.

“No doubt both of these avenues are important to pursue. Though the research pathway often feels like a delaying tactic doomed to encounter the same barriers that efforts to change laws face, House Democrats did on December 10 insert into an omnibus funding bill a provision lifting the ban on federal funding for gun-violence research. While the mental health care pathway, for its part, could have broader benefits, it would, at best, solve a tiny fraction of the problem — 3 to 5%, says Friedman, noting that “most people who are violent are not mentally ill, and most people who are mentally ill are not violent.” It also seems to make mental health workers or primary care physicians responsible for the impossible task of diagnosing and treating anyone who might conceivably start shooting people.”

On the date of the editorial’s publication, the House passed the omnibus funding bill with the ban intact, one ‘common sense’ measure that was ultimately a bipartisan decision. The CDC was never prohibited from researching causes and ways to reduce ‘gun violence’. It simply may not promote and advocate gun control, as it did until stopped in the 1990s. In fact the number of studies about ‘gun violence’ in the medical literature has not fallen, while studies in the fields of economics and criminology, which have a great deal to offer and are roundly ignored by public health ‘experts’, have added many more. They do get one thing right: it’s quite true that only a small fraction of violence is committed by the mentally ill, who are much more likely to be victimized.

“Most important, neither of these responses gets at the root of the problem. Something in the psychological or sociological makeup of the United States has left us at this long-standing impasse. Gun-control advocates blame the NRA, but perhaps the NRA is less like a foreign pathogen that has invaded our body politic, to which we could mount an immune response, than like a cancer, growing from our own mutated cells. And that dangerous mutation seems to be a sad distortion of the American principle of individualism that prioritizes one’s right to live the way one wants, without any government interference, over other people’s right to live at all — a distortion that has found one of its key expressions in firearm-related freedoms. But gun violence is an assault on the health of the public. An equally fundamental American principle holds that ensuring the public health sometimes requires curbing the rights of individuals in order to benefit and protect the community as a whole.”

So “the root of the problem” is now “the psychological or sociological makeup of the United States”, especially the “dangerous” “cancer” of the National Rifle Association? That won’t win friends and influence people. This insults all Americans who support a strong Second Amendment. It completely misconstrues the work of the nation’s oldest civil rights organization, whose influence comes from serving the goals of its millions of committed, activist members. I’ve never met any pro-gun rights person who “prioritizes one’s right to live the way one wants … over other people’s right to live at all”. Quite the contrary. The right to defend one’s own life and caring to defend others are the reasons that many people to learn how to use firearms.

“Ensuring the public health sometimes requires curbing the rights of individuals” [my emphasis]. That can very rarely be true, say, when highly contagious individuals must be quarantined (think Typhoid Mary). It is valid for real public health purposes like safe hygiene, with laws and codes requiring proper sanitation. But this is no justification to infringe on the general rights of law-abiding citizens to keep and bear arms, because guns are not infectious agents. The authors are clearly implying their desire to curb Second Amendment rights for everyone, which is a totalitarian impulse. Intervening with people at risk follows that model without infringing on enumerated civil rights. Examples include seriously enforcing criminal penalties, promoting initiatives like the Gang Violence Reduction Program, Project Exile and providing education about gun safety as do the ‘cancerous’ NRA and the National Shooting Sports Foundation.

“Previous commentators including Hemenway and Miller have listed among the steps toward reducing gun violence “changing social norms.” Given that it requires “deep cultural changes,” however, that is far easier said than done — it is, as Wintemute has argued, “the work of generations.” But it is work that we need to begin. If we never address the underlying beliefs that sustain this guns-everywhere extremism, we will not be able to diminish its power. Too many Americans will continue to get their hands on assault weapons, too many will kill or maim other Americans, and we will continue to bicker about whether the first step is more research or better mental health care — while we continue to do nothing to cure the disease.”

Social norms and the country’s attitude about firearms are changing. Respect for the right of self-defense and the means to exercise it keeps growing, while the desire to oppress gun owners and limit their rights keeps declining. This is the result of the very hard “work of generations” of civil rights activism, based on principles laid out by patriots at the very founding of America. Misrepresenting the virtue of acquiring the skills to shoot well demeans our countrymen who respect the role that firearms and responsible gun owners have played throughout our history—and will play in an increasingly dangerous world.

— DRGO editor Robert B. Young, MD is a psychiatrist practicing in Pittsford, NY, an associate clinical professor at the University of Rochester School of Medicine, and a Distinguished Life Fellow of the American Psychiatric Association.

All DRGO articles by Robert B. Young, MD.