Firearms and public health in the Americas

Why do half of the world's firearm deaths occur in just six countries, all in the Americas? What does consistently treating guns as a public health issue entail? Stephen Hargarten and Arturo Cervantes Trejo join Gavin to discuss their work with the Network To Prevent Gun Violence In The Americas.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to the Lancer Voice with me Gavin Cleaver. It's November 2022 and we're very happy to have you with us. Gun related violence is a topic never far from the headlines in the United States. So what is the extent of the harm to public health? How does the outsized ownership and production of firearms in the USA cause a ripple effect in Central America?

And what would consistently treating firearm ownership as a public health issue entail? I'm joined to discuss this by Stephen Hargarten, Professor of Emergency Medicine at the Medical College of Wisconsin, and Arturo Cervantes Tejo, Chair of Public Health at the Faculty of Health Sciences, Anahuac University in Mexico.

Both are members of the Network to Prevent Gun Violence in the Americas. Some listeners may find the discussion of gun violence that follows traumatic, so please exercise caution.

Arturo, Steve, welcome to the podcast. Thanks so much for joining us. Perhaps we could kick off by you telling us a little bit about this network to prevent gun violence in the Americas. Well, thanks, Gavin, and thanks for the opportunity 

Stephen: to be on this podcast. Arturo and I and others began to Examine a gun violence in the Americas several years ago when a report came out that showed that half of all gun violence deaths in the worlds are occurring in six countries in the Americas, United States, Mexico, Guatemala, Columbia, Venezuela, and Brazil.

And we found this to be remarkable and needing to address this and to talk about it, discuss it and explore. Research issues that further understand this problem and shed light on what policy options are, may be. So we formed this network about two and a half years ago, Arturo, as I recall, and we've been actively engaged in webinars and discussions research proposals and writings that we feel are important to get out and discuss.

Yes, I think. 

Arturo: What's an incredible background to this whole idea that Steve and I have been pushing for with the network is the National Academies of Science, Engineering and Medicine through the Institute of Medicine began in 2008, I believe, to get together to think I remember a meeting with Harvey Feinberg, who was the next dean of the Harvard School of Public Health, where they began to speak of this global public health pandemic as a major interest for the National Academies of Science and the Institute of Medicine.

And through 2008 through, I think, 2014, The Institute of Medicine convened a series of meetings and a lot of the books and publications came out of it that really covered the subject in depth through multiple perspectives. And I think that is a backbone of this whole effort together with the Violence Prevention Alliance out of the World Health Organization.

Which has been pushing for this topic strongly for a couple of decades now. 

Gavin: Now, I'm sure, you know, most of our listeners will be aware of the kind of scale of gun ownership in the U. S. And the two of you are based in the U. S. and Mexico. Just broadly, what's the scale of the harms caused by firearms in your two countries?

And also, Interestingly, why is the link between the two when it comes to like firearms traveling over borders and things like that? 

Stephen: Well, I think I'll start Gavin. The United States with surveys that have been done is in fact, the most heavily armed civil society in the world with over 300, estimated 390 million arms in civilian hands.

And this speaks to how perhaps then the marketing of firearms starts to the, the companies that make these products turn to other markets, turn to other places to sell their arms. And in fact, the United States is the largest exporter of small arms in the world. And so that has a predictable and has had predictable devastating effects in Mexico and other countries.

And our turtle can speak to that. With his with his leadership in Mexico and his work. Yes, in Mexico. Okay. 

Arturo: So what we've been discussing and part of your questions address these. Profoundly most of the countries are measuring the impact of violence by what we call the tip of the iceberg homicide.

And I will share with you that every year we're having around 36, 000 homicide. And usually statistics compare countries and places according to the homicide data, because that's the most. Important figure in terms of comparing nations and trends, but that's just the top of the iceberg. The, the, so the underlying iceberg includes up to 30 non lethal injuries that occurred to people that require medical attention for every homicide committed.

For every homicide committed with a gun, there's probably a. About 10 to 12 or 15 hospitalizations that require major surgeries and major treatments. This is injuries and pensional injuries are the major cause for labor issues in terms of bringing families into poverty and catastrophic health expenses.

You lose the family member, you lose the taxi driver, you lose the income generator. So the impact is not just on the dead person. It's on the physical, mental, emotional health and the community health of those around him. So you have to multiply that factor times four. Firearms are associated with a whole set array of other risk behaviors.

Such as alcohol abuse, and they're intimately related to domestic violence, to child maltreatment, which is going to have, you know, adverse childhood experiences, and kids that are growing up with their, with somebody in their family being shot, being killed, the impact of adverse childhood experiences, is Is a lifetime impact.

So it causes a lot of mental health needs, unmet needs, unmet demand you know, for services. And it just creates havoc in societies. And another thing they talk about how many guns they confiscate at the border. And it's 250, 000 or so, but this has been going on for 40 or 50 years and guns do not expire.

Guns are always useful and bullets and guns have flooded communities to an extent that were. Delinquency and kidnapping and armed robberies. And it's just it's a trickle down effect from a homicide, which is what we usually talk about to the destruction of the social fabric of the families that are affected.

And then of their entire neighborhoods, their entire communities, the tip of the iceberg, a homicide, but underneath it, the destruction is unbearable. 

Gavin: It's quite compelling, isn't it? Because when you think all the way down, you know, we're talking about homicides, as you said, they're a tip of the iceberg.

When you think all the way down to even the kind of mental effects on a person of having a gun pointed at you, you know, of being made to do something against your will at gunpoint, even though there's no physical harm visited upon you in that circumstance. It's still an incredibly kind of traumatic experience, but that's all the way down.

So, you know, we're only talking about physical harms here a lot of the time, but it's, you're right. 

Stephen: It's such a huge scale. You know, and then come back to what Arturo was saying here in the United States, bullets are the leading cause of death of children and adolescents in the United States today.

And if you are injured with a bullet and get hospitalized, our recent studies. Demonstrate there's an increased access need for behavioral health services. So to that ripple effect that Arturo was explaining that broad ripple effect that goes across not only the individual. Who's harmed by a bullet that's carried by a gun.

The families are affected. The local community where this happened is adversely affected. Lots of things are rippled from that event. And I think that's a real major, largely undescribed area that needs to be further examined. And so that tip of the iceberg that Arturo mentioned, homicides, in the United States, it's also suicides.

That are occurring across the United States. These are really important to get beyond that and get into how this also adversely affects families, friends, and communities. 

Gavin: quickly talk about the other countries in Latin America that really suffer from gun violence. And that really striking statistic, 50 percent of gun harms worldwide happen in those six countries.

So how, how reliable generally is this data that we have? Of course, we've been talking about how firearm ownership and misuse has this huge wide ripple effect. And so that seems quite difficult to quantify generally, but what do we know about it in, in other countries? 

Arturo: It's a very important question.

Because the data is very hard. There is hard and good data from national surveys. The whole, each country participates and has national crime and victimization surveys with representative samples of the entire population. And we've been doing this in Mexico for over two decades and in other Central and Latin American countries as well, vital registrations are a very, for death certificates.

Are a very reliable source in the Americas. And I would say that they are fairly, fairly good specifically in terms of victimization, not from homicides, but for the other issues like robberies, crimes, the surveys are the most important tool that is used by countries. So I would say that we have reliable data on the insecurity, on crime, on, on deaths of people on hospital admissions.

In many countries, it should be improved, but with the data we have, we know there's an epidemic. 

Gavin: So how does firearm production in the U. S. affect these 

Stephen: other 

Gavin: countries? 

Stephen: So if I can start with that you think about companies like the tobacco companies who want to sell products. And when they either saturated the U.

S. market or they were adversely affected with policies that we're intended to do decrease usage. They turned to other markets and it's no different in my opinion than for companies that manufacture small arms. And so the companies want to sell sell product. And what we have been focusing on with the network.

Is how this product, the guns and the bullets they carry, make their way through a variety of mechanisms, through the border in Mexico or through shipping to Central America and other ways. End up in illegal hands. It's a natural course for a company to, they want to sell product. They want to distribute their products.

And in this case, they are looking at other markets. And this has, as Arturo is so well described, has significant adverse outcomes. 

Arturo: You know, in the lawsuit that the Mexican government and us as part of the network, help the Mexican government prepare this lawsuit against makes a us artist maker. It's clearly described.

How this pattern of a toxic industry hiding its its practices and hiding what they know and keeping pushing, fighting legally to open channels, continue doing this. One of our partners, Stop U. S. Arms to Mexico, you can go on their, on, onto their website and you will see. That we have mapped the number of stores.

There's over 65, 000 gun dealers in the United States. And many of them are what we call hot ones where it's known that they are selling to, to straw purchasers and to people who are bringing them in. And now they don't even assemble them. They're bringing in parts. So it's a very well organized transnational criminal organization that is laundering money and bringing in guns to the region for decades.

We have a lot of knowledge and we're planning to start a registry of firearm deaths. And firearm injuries for the region, such as the one you have in the United States. 

Gavin: So when we're thinking about kind of public health approaches, and we'll get on to talking about guns as a public health issue in a minute.

What are some of the approaches currently taken towards gun harms on a public health level? 

Stephen: So I think that that's a very timely question Gavin, because public health. Sciences and public health approaches are a variety, and I think what Arturo just mentioned about the epidemiology, understanding the scope and nature of this public health problem is so important to accurately describe, employing these public health sciences of epidemiology and statistics to clearly outline the scope and nature of the problem.

But what Arturo also mentioned was a lawsuit, tort. In the United States, we have used this public health tool. to force car manufacturers to integrate car safety features in their, in their cars, like airbags. And so now the recent tort brought forward by the Mexican government to the manufacturers of these, of these products, to the dealers of these products in Arizona, to, to, they are engaged in a lawsuit to have them clear up, to clean up, to be more responsible for the distribution of their product and for the sale of this product.

And it's a classic public health approach that we feel is so timely and important. And that gets back to the origin of the network, which was the focus of the vector of this disease, the gun, the AR style 15 rifle, and the bullet, which we feel is the pathogen of this disease. And we think about exploring how the movement of this product goes from the factory in the United States to a dealer in Arizona to an illicit buyer in Mexico.

And we feel this is an, that the public health approach is an important way to frame this, to understand it and employ sciences that help us further understand this pandemic, just like we do this for other problems that have vectors. And pathogens such as Zika such as dengue, such as other ones that we feel we can apply to this problem and the distinct feature is we know where they're made as opposed to a mosquito, which is a far more distributed a vector of disease.

And so it's, I think it's an important area Gavin, that we feel strongly about that this is important to be examining this as a public health. Crisis of public health pandemic. Let me 

Arturo: add there the spoiler, okay? We've known about this mechanism for disease in society and we've labeled it and seen it as a public health issue.

I'm talking about the scientific community for almost five decades or maybe a little, five decades or a little bit more. And in the United States, it was Surgeon General Everett Koop in the 80s, I believe he was Surgeon General, that he declared violence a public health emergency nationwide. This was in the 80s, and this was an incredible look at violence.

I think, throughout the decade of the eighties and nineties very important groups and majors in Boston, for example, that were a pro for state, became a major in Boston and began to address violence as a public health issue in the nineties. In the nineties in many inner cities. And this movement has solely grown stronger with the World Health Organization, issuing several discussions about this topic in general, assemblies and.

This is the most important part of this paradigm, the public health paradigm. It's a science based, very, very concrete, very objective science based approach to disease, which has to do with spatial epidemiology, tracking the disease in the social spaces, in the geography of cities, and looking at risk factors within individuals.

It's a, it's an ecological framework to understand. Why violence affects one person, you need to look at his friends, at his family, at his relationship. So this whole ecological framework approach, so what I'm emphasizing, Gavin, it's a 50 year theory that's been strengthening every year ever since. And most importantly, it's a multidisciplinary approach.

It involves the police, it involves teachers, it involves emergency doctors, it involves physicians, psychiatrists. This disease. This social disease, this individual disease requires a coordinated effort among actors that intervene. And just to tell you, we have so much evidence from throughout the world, from many cities, including London, including in Ireland, in Scotland, of this approach working.

And For example, in, in Ireland, in Scotland the police chief made a virus prevention unit in the Scottish police. And I'll remember his name as we speak, but the, the public health approach was at the forefront of the police work for this Scottish virus prevention unit. And you know what it worked and they measured it and they have very concrete interventions, not only for victims.

But for avoiding juvenile delinquents, for avoiding perpetrators, for working with them at the early stages of their life, early childhood, for avoiding adverse childhood experiences. So this is some very consolidated field of knowledge and of science. And unfortunately, for low and middle income countries, for Spanish speaking countries, for Mexico, this, what I just spoke about, is completely off the radar.

Nobody knows this. Nobody, what I, what I could tell you about this body of knowledge, and that's why your work at the Lancet is very important for us this is not well known. And there's, I did mention probably a dozen or 20 examples. If we have the time of cities that have proven reductions, 30%, 40%, 50 percent reductions in crime and violence related to guns, if they just get the resources and the funding that they need to operate, and most importantly, the professionals that know about this model and that know how to implement.

It's 

Gavin: very interesting to think about, you know, gun harms and gun violence prevention as a sort of infectious disease initiative, as you were talking about that. What are some of the, what are some of the kind of direct interventions that you propose? 

Stephen: Well, again, to start with we're a network that facilitates discussions about this, but I think strengthening the enforcement of.

straw purchasing and other regulations that are under the purview of the Alcohol, Tobacco and Firearm Explosives Bureau of the United States government is one area that is so important to strengthen. And with the recent appointment of a leader in this, for this bureau, we see this Hopefully to strengthen their their approach to these dealers to assure that they are operating legally and reducing straw purchases.

We feel with our research proposals that. We think that the governmental agencies of the United States, for instance should be working closer together. And in fact, there are many places where guns are confiscated by several agencies of the federal government in the United States, but they're not talking to each other.

They're not. Combining their information about the, where these guns come from, where did they originate for their first sale? And we feel that's an important area that provides trended information about where these guns are coming from. So that investigations can be more focused towards these nefarious gun dealers to populate the borders from California, Arizona, and and Texas.

So. Those are some examples of, we feel, important initiatives to control the vector of this public health problem. 

Arturo: In Mexico, unfortunately, this problem is not being addressed as a public health problem. Even Joe Biden, for example, has recently declared this a public health issue. And it's investing major funding through the CDC and violence institutes for research to be conducted in all areas of this phenomena and how to approach it.

But unfortunately in Mexico, what rules is the old paradigm, the paradigm that doesn't work, the paradigm where knowledge is not being taken into consideration. For addressing this issue from the multiple perspectives that it needs to be addressed, I would call upon the, the vision of the SDG, the pathfinders for SDG 16, which Mexico is talking about, and that we are a member of this international need, which is using Agenda 2030 and the sustainable development goals, specifically SDG 16.

As a lot of issues of a comprehensive action for violence prevention and specifically for gun violence prevention. SBG 16 has the vision that if we wanted to reduce violence by 50 percent by 2030, we need to tackle all forms of violence, childhood violence, domestic violence, intimate partner violence.

So SBG 16 provides a framework for looking at this towards 2030 with concrete objectives, reducing injuries as well. But SBG 16 also has. Other aspects such as illicit money and laundering of money illicit, illicit flows of international. International illegal flows of firearms for more transparency and stronger institutions.

And I'm speaking out of memory here, but you get the picture. There is a whole vision of how we meet to address this problem, looking at risk factors, both at individual, family, community, and macro level using the ecological framework. And if you want a specific interventions that work, that we know are proven to work.

Let's talk about guns and alcohol, for example it's proven interventions to reduce alcohol consumption have a lot to do with violence prevention, even indirectly, but gender issues and social norms have a lot to do with violence prevention and gun violence prevention, the macho culture about domestic violence, you know, most homicides among women.

Which by the way, have been increasing made by their partners with guns that they buy for cheap bullets. And most of the violence towards women that ends up in homicides is conducted by an internet partner. So the way to address a lot of these issues takes into account these risk factors in these contextual factors.

And as you call them. The social determinants, Gavin. 

Gavin: I think I know the answer to this next question, but I think it's very important to talk about anyway. To what extent does the gun lobby kind of stymie the research, particularly into firearm violence? And what are some of the ways that gun regulations kind of stop you from treating firearms like a public health issue?

Stephen: We talk about what's happened over the past two plus decades. There was an unfortunate development in the 1990s that dampened our ability. It did not prohibit our ability. It dampened our ability to conduct research with the Dickey amendments that called for not being able to use federal funds to advocate for gun control.

And it was a most unfortunate, um, policy that resulted in the federal agencies in the United States. being wary of supporting research, which again, research was able to be conducted, but the leadership of those agencies were very, very wary of promoting research because of the Dickey amendments of presence and the disclaimer that one has to swear by when you receive federal funding to do firearm related research, which I received in the, in the 2000s years.

And so that dampened research efforts significantly because there were no federal funds available. Some foundations in the United States picked up some of the support for this, but it really did have a untoward effect towards future researchers who are not interested in this area because it is so politically charged relative to other public health problems that one can develop a career around.

So there was a dampening of, of research, a significant dampening, Gavin, here in the United States. And I think that had adverse ripple effects with other countries not seeing. Any research coming out from the United States as an example. So that has led to now most recently a relative increase in interest with the federal government now funding gun firearm related research, both at the CDC and NIH.

And we are in fact, having a major research conference in Washington, DC in late November, early December. And it's really the first national wide meeting that has occurred in the United States for, for many, many years. And so I, I am hopeful that this is changing in the right direction and will then further inform programs and policies that decrease firearm related deaths and injuries, not only in the United States, but now this effort that I'm referring to will intentionally pull in researchers from around the world, particularly in the Americas.

To learn from others, as Arturo mentioned, some cities have made gains. How do they do that? What can we learn from other places where research has been conducted to help us further understand how we can decrease this toll, how we can make our communities healthy and safe for everyone. Yeah, I mean, this is like a David and 

Arturo: Goliath paradigm because.

As in the tobacco industry, the garden industry might be even much more powerful. Eh, what did we call them, Steve? The commercial determinants of public health? Yes. Which has incredible lobbying power in the States or European countries where lobbying works. Has an incredible corrupting power. So the people, the few people who are at the top of this reign are controlling strings and that.

No ordinary citizen will, will ever be able to surmount. We know that around 70 percent of weapons discovered in Mexican crime scenes come from the U. S., are originated from the U. S., but we are only able to track a very small amount of guns because tracing systems are not open. They are hiding the data.

They don't want us to discover where the guns are being manufactured and how they're coming into the countries. of unstoppable in a sense, but we will not stop because it's it's an insurmountable obstacle of of political and commercial interest. What do 

Gavin: you think it will for some kind of tipping point to be achieved in the sense of a commitment to clamping down on guns as a major source of public health?

I think in Europe, we've. Always looked at the U S and gone, for example, you know, the recent school shootings, the one in New Valdez in Texas and the one in Sandy Hook, we've looked at those and gone, surely this now will be the moment where the United States will do something similar to what the UK did after the Dunblane school shooting and clamp down on, on the guns, but nothing ever happens.

You know, if anything, it just gets worse. So. Could you anticipate any kind of like tipping point where actually this becomes something that the public, that the government become heavily invested in, in this kind of, in better gun control? 

Stephen: Well, I can speak to in terms of the United States, we, I think we're going to have to have a few more events, but also we need to have.

Federal and state administrations to examine policies that are permissive or policies that are needed to be enacted so that we can strengthen the, the regulations about guns flowing from the United States to other countries. And that unfortunately happened in the previous administration where the oversight of gun exports was removed.

Primarily moved from state department to the commerce department. And many of us are working towards changing that back to state to really have a rigorous enforcement process for the export of guns from the United States to other countries. And so I don't, I don't have a, I don't think there's going to be an actual point, a tipping point, but I think a series of, of events, a series of, of actions such as the lawsuit that the Mexican government has put forward is an example of movement and of opportunity to show that if indeed these this lawsuit advances, that that would be a very, very positive development, The lawsuit against Remington that was successfully made with the Sandy Hook survivors was an example of, of a positive outcome where there was a settlement for the advertising of this product.

And so I think there are some steps that have occurred and are occurring that are hopeful that are, I think, beginning to get more and more. U. S. civil society support that I think will result in a steady decrease, hopefully, in the, in the, in the years ahead. I don't want to sound overly optimistic. I've been at this for over 30 years as Arturo had, and you, you have seen this ebb and flow.

And I too shared, I thought Sandy Hook was going to be the tipping point. I thought Yuvaldi might be that other tipping point. And yet I think it's accumulating more and more efforts from a lot of different organizations that weren't present 20 years ago. And I think the other part of this is that the NRA is not an insurmountable organization as it has been in the United States, and that the target can and should be the manufacturers.

And that's where some of us, including researchers in London, are looking at commercial determinants of health and having firearms as a product. As a commercial determinant of health, no different than tobacco is. And so I think those are other incremental steps that are beginning to accumulate. And I'm hopeful that this will continue to pay dividends and that we'll start to see some control of this product.

Gavin: Well, Steve, Arturo, it's, it's a difficult topic to talk about, isn't it? It's it's emotional and kind of thinking about the breadth of harm visited on, on people around the world by guns is it's very sad to talk about, but I feel a little bit more optimistic now, having spoken to you both. But thank you so much for, for joining me on the podcast and sharing your expertise in this area.

And I wish you the best of luck in in the future.

That's it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessamyn and I on Twitter on our handles at Gavin Cleaver and at Jessamyn Bagonall. You can subscribe to The Lancet Voice, if you're not already, wherever you usually get your podcasts. And if you're a specialist in a particular field, why not check out our In Conversation With series of podcasts tied to each of the Lancet specialty journals, where we look in depth at one new article per month.

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