Thursday, July 26, 2012

A Physician’s Take on the Shooting in Aurora, Colorado

Let me begin by saying that the news of this event was truly shocking to me. In those hazy early hours of the news reports, I wasn’t clear as to where the shooting had taken place, and my thoughts automatically went to my friends in Colorado, as well as my many friends who have family in Colorado. Fortunately, no one I know was injured or killed in the shooting, but even so, the event weighs heavily on me. I am probably only one of many who are most dismayed by the fact that this shooting, though undoubtedly horrific, is not unfamiliar to us Americans – the recent shootings at Café Racer in Seattle, Arizona representative Gabby Giffords’ shooting, and many, many similar events seem increasingly common. These events may not actually be becoming more frequent, but they bring into sharp focus a general problem with gun violence in America. As horrible as it is to hear of even one death, let alone fourteen, it should be pointed out that, if July 19th was a day like any other in America, the fourteen killed in Aurora were matched by another 70 Americans who were shot to death elsewhere.

I make an effort to avoid political topics in this blog, so I don’t want to address this as a political topic. I’m not going to be discussing the constitutionality of gun ownership, I’m not going to be discussing the NRA, and I’m not going to be discussing responsible ownership. I have a number of friends and colleagues whom I respect enormously who are gun owners, and I don’t have any interest in causing offense. I want to discuss this as a public health issue.

Let’s first do some basic math. Several sources (1, 2) I’ve read have stated that 84 Americans are shot to death each day, and that about twice that number are injured by gunfire. A quick expansion would suggest that 30,660 Americans are killed by guns per year, and 61,320 are injured. Because I’m using rough figures, I’ll round them down to 30,000 and 60,000.

To put these numbers in perspective, here are 2009's death rates for some other leading causes of death (2009 is the most recent year published by the CDC). Heart disease continues to top the list, claiming nearly 600,000 Americans in 2009, the most recent year I was able to find. Malignant neoplasms (cancer) come in next at approximately 568,000. The numbers fall sharply after this, with chronic lower respiratory diseases coming in third place at 137,000. The numbers keep going down, through cerebrovascular disease, Alzheimers, diabetes, kidney disease and others.

Included on the list are accidents/unintentional injuries, intentional self-harm/suicide, and homicide – gunfire is not listed separately by the CDC, but we might assume that guns cause a portion of the deaths in these categories. If gun-related deaths were counted separately, and the figures listed above are accurate, gunfire would have been the 13th most common cause of death in 2009, placing right between chronic liver disease/cirrhosis and essential hypertension/hypertensive renal disease.

So how do we interpret these facts? Let’s look at how physicians have responded to the other major causes of death.

Clearly heart disease and cancer are the two biggest killers in America, by a significant margin. In an effort to stem the tide, the American Heart Association and the American Cancer Society have launched massive awareness campaigns, and physicians are actively engaged in efforts to prevent these diseases. We encourage healthy eating and exercise, we encourage patients to quit smoking, we order imaging studies, we order labs, and we use medications to reduce the likelihood that our patients will die from these causes. In the political arena, we’ve banned smoking in many public places, a step that is aimed at these two causes of death, as well as the third cause of death, chronic lung disease. In short, we're hard at work combatting these diseases.

Even with some of the less common causes of death, we have taken measures to prevent them. At an annual physical, a doctor screens not only for heart disease, hypertension, cancer, and lung disease, but also kidney disease, liver disease, depression, and a whole host of other causes of death. When I was still in training, our clinic’s intake sheet even had questions about seatbelt and helmet use. Many of these are so routine that they involve little more than checking a box. As patients, many of us have our liver and kidney function checked without even knowing it or with much discussion. Why then, as doctors, are we not asking our patients about gun use or safety? As a cause of death, it’s at least as important as these two other diseases, and yet we as doctors are doing very little, either in our offices or politically to reduce deaths due to gunfire.

Some of the other causes of death are more complicated. Heart disease and cancer are a complex mix of environmental and genetic factors, and while they are largely preventable, it’s unlikely that we will ever get a full grip on these diseases. Deaths due to gunfire, however, are far more preventable – there will be occasional accidents, but I think we can all agree that deaths due to gunfire are nearly entirely preventable. We as physicians work hard to prevent these other causes, and it’s high time that we made an effort to prevent gun deaths as well. As I stated at the beginning of the article, I’m not going to make this political, but as physicians who have taken oaths to do no harm and to alleviate suffering, I believe we have an obligation to do what we can to combat death and injury due to gunfire.

(For those interested, here's a petition to Pres. Obama and Mr. Romney on behalf of the Brady Campaign.)