Where We Can Stop the Bleeding
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Buying a machine gun is legal in Nevada, but it is expensive. Retrofitting a semiautomatic rifle so that it will fire like a machine gun, on the other hand, is easy, and comparatively cheap. Stephen Paddock was reportedly wealthy enough to afford the former but chose the latter before killing 59 people and injuring more than 500 others on Sunday night during a country music festival in Las Vegas.
This is how it works in the United States, a country where there are more firearms than people: We are rich with options when it comes to harming others or harming ourselves.
In the days since the massacre, a familiar kind of theater has played out. There is no real split among a majority of Americans when it comes to basic gun reforms, but a divide is nevertheless entrenched in our Congress and our state legislatures. This means our political horizons are limited by the fact that the National Rifle Association has an ungodly amount of money, an energetic army of dedicated extremists who turn out for Republican primary elections, and, hence, a policy lock on a staggering number of our elected officials. So instead of changes to our laws, we get thoughts and prayers, and admonishments not to politicize tragedy. Then the tragedy fades into the soft focus of the recent past, only to be replaced by fresh tragedy. Then we start over.
This grotesque repetition at least gives us the benefit of knowing where we stand: There have been dead children and dead churchgoers and dead college students, but Congress will not act.
This way lies defeatism. But the reality is that, despite the gun lobby having its boot firmly lodged on the American neck, there is some space for policy and cultural intervention that will help prevent preventable deaths and blunt other harms associated with unfettered access to deadly weapons. So you stop the bleeding where you can.
Part of the dilemma here is that mass shootings have come to define when and how mainstream political discourse turns its attention to gun violence in the first place, when they are actually a small fraction of the problem. Most firearm deaths in this country are not a consequence of high-profile massacres—they are suicides. Specifically, six in 10 gun fatalities in 2012 were death by suicide. And the demographic most likely to die this way also happens to be the demographic most likely to own (and fiercely resist the regulation of) guns: white men.
However resistant a politically powerful minority of the population may be, the gun policy approach here is straightforward enough: explicit waiting periods, or background checks and licensing requirements that amount to de facto waiting periods, are associated with lower suicide rates.
“There is often some event—you lose your job, you have a fight—that triggers the decision,” Dr. Cassandra Crifasi, an injury epidemiologist at Johns Hopkins University and a faculty member at the school’s Center for Gun Policy and Research, told me last year. “The idea is that if we could prevent somebody from getting access to the gun in that moment of crisis, then we could help reduce suicide.”
Crifasi and other researchers at Johns Hopkins went ahead and tested this theory in 2015. In 1995, Connecticut passed a law that required potential gun purchasers to first complete hours of safety training and apply for a permit with law enforcement. In the 2015 study, researchers compared Connecticut’s gun-related suicide rates to gun-related suicide rates in Rhode Island and North Dakota, which are demographically similar to Connecticut but don’t have similar gun restrictions. Ultimately they found that the Connecticut law was associated with a 15 percent drop in gun-related suicide in the 10 year period after it was enacted.
The reverse was true for Missouri, a state that repealed its permitting requirements in 2007. In the same study, researchers estimated that the gun-related suicide rate increased by nearly 16 percent after the requirement was lifted.
So what of the states that will not enact waiting periods—or the local governments blocked from enacting them by a blanket of preemption laws that override their ability to regulate firearms?
Targeted public health interventions, which in many ways are just as politically contingent in a country where healthcare is not considered a right, offer some space for negotiation. A Detroit program founded in 2001, rigorously implemented and holistic in its scope, has produced a dramatic reduction in suicide rates among its treatment population.
From an NPR report on the Henry Ford Health System’s approach, which they call “perfect depression care”:
Primary care doctors screen every patient with two questions: How often have you felt down in the past two weeks? And how often have you felt little pleasure in doing things? A high score leads to more questions about sleep disturbances, changes in appetite, thoughts of hurting oneself. All patients are questioned on every visit.
If the health providers recognize a mental health problem, patients are assigned to appropriate care—cognitive behavioral therapy, drugs, group counseling, or hospitalization if necessary. On each patient’s medical record, providers have to attest to having done the screening, and they record plans for any needed care.
Therapists involve patients’ families, and ask them to remove guns or other means of suicide from their homes. Clerks are trained to make sure that patients who need followup care don’t leave without an appointment. Patients themselves come up with “safety plans.”
The system includes 200,000 patients, and in the decades since the program first started, it has reported an 80 percent reduction in suicides. The rate within their general population is five per 100,000. The national rate is closer to 13 per 100,000.
Talking about expanded access to treatment in this context is not the same thing as Republican lawmakers cynically deflecting questions about gun reform by calling for nominal changes to our mental health system. People with serious mental illness are more likely to be victims of violence than they are to be perpetrators, and these are almost always the same lawmakers who have worked doggedly to try and eliminate mental health as an essential benefit. It has a place in the conversation around gun violence, just not the one being offered right now by Republican leadership.
“Not all suicides are the same,” Dr. Stephen Hargarten, a professor and chair of the Department of Emergency Medicine at the Medical College of Wisconsin, tells me. “So understanding suicidal ideation and what drives people to do that” is essential to developing the range of strategies necessary to do something about it.
“It’s a little bit like when you think about car safety,” according to Laura Cutilletta, legal director at the California-based Law Center to Prevent Gun Violence. “It wasn’t just one thing—it wasn’t just reducing the speed limit to 55. It was seat belts and air bags, constructing cars differently.”
Guns may present a more complicated set of challenges to overcome, she says, but this kind of diversity in approach—both in terms of expansive policy considerations and what are ultimately going to be normative cultural shifts—can add up in the longterm.
Which is where we arrive at the intersection of domestic violence and gun violence. A multi-state study published in the Journal of Public Health found that the involvement of a gun in a domestic violence incident increases the likelihood of a homicide by 500 percent. This kind of lethality is entirely unique to the United States.
Despite this, current federal law only prohibits people convicted of misdemeanor domestic violence from owning guns if they are married to, have children with, or live with their victims. Right now, more than half of all domestic violence homicides are committed by a dating partner, so the consequences of this gap in policy are obvious enough. In majority of states, these abusers are permitted to own as many guns as they might like.
But this is also happens to be an area where certain states, even those under Republican-control, have been willing to enact gun laws that expand, though sometimes narrowly, protections for victims. The process has been slow and painfully uneven, but it seems that the politics around this specific set of policies has shifted some in recent years. In the last three years, more than a dozen states—including Louisiana, Rhode Island, Tennessee, and Pennsylvania—have acted to consider or expand protections for dating partners.
This is a sliver of possibility in an otherwise dark landscape, but just as pressing as the laws themselves is the thornier question of enforcement. (This, and the fact that most men who abuse women will never be convicted of any crime and so will never be subject to any such law where it exists.) Enforce the laws you have is often an anti-reform deflection, but it’s also a serious demand when you’re trying to reduce harm.
This is true even in states considered friendlier to gun control. As The Trace reported last year as an example of this gap: “In Maryland, the nonprofit group Court Watch Montgomery released a report that found that out of 126 disqualified offenders, only one had learned that he could no longer possess a firearm.” Rhode Island, which has a gun relinquishment policy for those convicted of domestic violence, faces a similar lag in enforcement and a lack of awareness about existing law.
These are the contours of our current predicament. Until Congress is remade into anything resembling an accountable body, the country faces a dismally constrained set of options. Piecemeal change that seeks to limit harm where it can is and will remain wildly inadequate in response to the current level of violence, but the alternative is a kind of paralysis.
A relatively small percentage of the country, with the backing of a well-resourced network of lobbyists directed by the whims of the arms industry, has an iron grip on how this country currently regulates guns. While working to change the political dynamics that make that possible—voter suppression and gerrymandering come to mind—the body count rises.
“It’s a much more multifaceted problem than some of the other public health issues in society,” Cutilletta says of gun violence more generally. “But in a way that’s an opportunity.” There is no other option but to take it.