Thursday, July 10, 2008

The New England Journal of Medicine & Handguns: Fair Assessment of the Threat to Public Health?

The Disease Management Care Blog wandered from the usual fare and stumbled upon this editorial by Greater Gods of the New England Journal of Medicine. In it, they apply a public health perspective to the recent decision by the Supremes overturning the District of Columbia’s approach to banning regulating handguns within its borders. They predict that pre-post ruling measures of handgun related injuries in places like San Francisco, Chicago and D.C. are destined to show an increase in avoidable death rates. They particularly worry about the children who account ‘for a quarter of the nonfatal injuries and a tenth of the deaths.’ Their concern is about ‘the health of the public, especially young people, whose safety is disproportionately affected by firearms.’ If an outright ban is not possible, they suggest re-jiggered regulations that result in the same outcome are not only necessary but still possible.

The DMCB likes the prospect of using ongoing data to inform public policy. What do they tell us?

Check out this information that was collected from the National Center for Health Statistics listing the top ten causes of death for young persons in the United States. ‘Unintentional’ injury is the leading category and within that, ‘motor vehicle,’ ‘drowning’ and ‘fires’ far exceed ‘firearms.’ ‘Homicide’ accounts for a significant number of intentional deaths and handguns are undoubtedly an ingredient in some of those too.

However, motor vehicle injuries and drowning remain the number 1 and 2 leading causes of death in children. They and fires as well as suffocation, poisoning and falls outnumber deaths from firearms. How is it then, that firearms (and handguns in particular) deserve so much attention from a ‘public health’ perspective in the New England Journal?

To the DMCB it appears speed limits, licensing, inspections, policing and child restraint laws are a reasonably balanced approach for the number one cause of death, but where are the regulations or bans that would promote better water safety? Absent outlawing kids on car trips to grandma’s and forbidding any swimming in her pool, do not health care professionals have an even greater reason to be concerned if childhood death rate from unfettered bathing is comparable to the metric used by the Journal, the ‘number of deaths in Iraq?’ Aren’t children also, if not more, vulnerable to the threats posed by private and public bodies of water?

Possible regulatory options could also include licensing (for private pools and lakeside property if children will be present) as well as regulations promoting fencing, alarms, first aid availability, CPR training, shallow water depth and lighting. It may seem silly (and it is), but fair is fair: death by handgun is no less horrid but far less prevalent than drowning. But if we must, both may deserve the same treatment if public health regulation is the preferred approach. Unfortunately, editorializing about only one is far sexier. The DMCB is looking forward to future editorials promoting not only water safety but other prevalent causes of childhood death including prevention of suffocation, poisoning and falls, to name a few.

It’s their Journal, so the Editors can do what they want. The DMCB takes issue, however, with the patina of ‘public health’ and ‘children’ to support an anti-gun bias. Public health principles should be applied consistently and address what is important first. Secondly, if you don’t like handguns (and the DMCB isn’t too sure it likes them either) just come out and say so without resorting to spinning the health statistics. The readers of the Journal deserve better.

Finally, the DMCB doubts the Editors can have it both ways. One week prior, the Journal published an editorial by the same authors criticizing the use of a regulatory process that would shield pharmaceutical companies from allegations of injury in a court of law. In their handgun piece, the editors support the use of regulations that undercut the due process that eventually lead to the majority reading of the Second Amendment. It appears due process, regulations and decisions in courts of law are selectively supported by the Journal only so long as they agree with the opinions of its Editors.

Post script: Not wanting to be a complete nattering nabob of right wing nut-job negativity, the DMCB would like to point out that the disease management community can do more than just editorialize and advocate for more regulation and litigation. In addition to coaching parents about car and water safety, there is good information supporting the evidence-based options of promoting gun safety, proper storage, use of trigger locks and increasing physician awareness.

No comments: