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Target prevention: Researching the epidemiology of gun violence

Garen Wintemute, MD, MPH, doesn't hate guns and isn't trying to get them banned. He does want to stop the bone-shattering, blood-spurting, life-ending injuries that guns can cause.

By Kathleen F. Phalen, amednews correspondent. Aug. 20, 2001.

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Emergency physician Garen Wintemute, MD, MPH, says he's a crisis junkie. It's all about making a difference in critical situations. But that's not always easy, especially when the physical damage is almost irreparable. Like when he was in a bush camp during Cambodia's civil war, treating 20 or more combat wounds each day. Or now, working 12-hour shifts in the University of California, Davis', urban trauma center in Sacramento.

These are places where wounds are sometimes hard to treat. Where torrents of blood are common. Where time equals death and injuries paralyze and kill. These are the kind of wounds that come from guns -- bullets tearing through flesh, tissue and bone.

"Guns are unique among weapons. The chance of dying is much greater than with a knife," says Dr. Wintemute, professor of epidemiology and preventive medicine at UC Davis.

"Most people who die from gunshot wounds die where they are shot. And those who receive care die within the first 24 hours."

The injuries Dr. Wintemute treated during his three months in Cambodia's war zone are not that different from those treated at any urban trauma unit: insidious, life threatening and violent. There's the bleeding kid dumped out of a gang member's speeding car, the suicidal woman who shoots herself but now wants to live, the boy who aims at his 2-year-old sister thinking the gun is a toy, the store clerk trying to avert a robbery, the hunting trip gone bad.

Nearly 40% of American households have guns. There are about 220 million firearms in civilian hands. And there are more than 30,000 firearm fatalities each year in this country. For every death there are approximately three nonfatal firearm injuries, according to the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention.

What really troubles Dr. Wintemute is that there is little more that can be done clinically to alter the course of these fatalities. Emergency care of gunshot victims is already skilled -- with paramedics starting care in the field and highly specialized trauma teams taking over in the hospital.

"The only effective way to treat a gunshot wound is to keep it from happening in the first place," says Dr. Wintemute. "I decided it was time to start preventing what I was treating."

Gun research is volatile. So for two decades, Dr. Wintemute has been treading where few dare go. And he's not afraid to get into the thick of it.

Like the time he believed a photo excursion along the Connecticut River Valley, aka Gun Valley -- home to all the major firearms manufacturers -- might help people understand.

"We had decided to take what we knew about public health prevention and apply it to firearm violence," says Dr. Wintemute. "We equated the loading dock to smokestack pollutants."

Boarding a train in Baltimore, along with his former public health policy professor Stephen Teret, MPH, Dr. Wintemute set out to visually document where guns are made and transported.

"We wanted to show upstream sources," says Dr. Wintemute. "We used slide film. We wanted people to understand guns come from somewhere. And people got it."

It was Teret who hooked Dr. Wintemute on this gun issue in the first place. And now it's at the core of his life's work.

"Since 1990 I have been focusing exclusively on gun violence; it's a huge problem. Gun injuries are one of the 10 leading causes of death in the U.S.," Dr. Wintemute says. "There is relatively little research, even today, and I had a sense that this would give me a chance to make a difference."

The two co-authored an article on gun policy while Dr. Wintemute was still an MPH student at Johns Hopkins University School of Public Health in Baltimore in the early '80s.

"I remember noticing him in the back of the room full of students -- he already had his MD when he came here -- I remember thinking right then, this may be that student you hope for in your teaching career. He seemed outrageously smart," says Teret, a professor of health policy at Johns Hopkins School of Public Health who also directs the Center for Law and the Public's Health. "It proved to be true. The fact is he has accomplished, in this area, more than anyone in the world. His work has and in the future will make substantial policy changes that will save lives."

In 1991, Dr. Wintemute started and still heads the Violence Prevention Research Program at UC Davis, and he's garnered a loyal and almost gurulike following.

There are those who marvel at his brilliance, his creativity, his charisma, his willingness to break new ground. "I'm in public health now because of him," says Shannon Frattaroli, PhD, assistant scientist at the Johns Hopkins School of Public Health.

Dr. Wintemute was her professor. "He conveyed that we can make a difference in the way people live in this world. He gave us the tools and confidence to set out on a path."

His research findings have helped change laws, regulations and policy. In a 1987 JAMA study, he linked children accidentally killing children to the similarity between toy and real guns. A nationwide media frenzy led to a manufacturing change in the appearance of toy guns.

In the '90s he focused on "Saturday night specials," those cheap, easily concealed starter guns that were heavily manufactured in Southern California, a place he termed the Ring of Fire. In 1992, six family-owned manufacturers produced 685,934 of these handguns. Today a number of states have banned the manufacture and sale of Saturday night specials. Two of the companies manufacturing them are out of business, one went bankrupt; and the rest have had a nearly 15% decline in sales.

Dr. Wintemute talks about how people are 50% more likely to commit suicide during the first week after they buy a gun. And how denying felons handgun purchases has been associated with an approximately 20% to 25% reduction in their risk of committing new gun and/or violent crimes.

"I admire the hell out of his research," says Bob Seltzer, PhD, executive director of Doctors Against Handgun Injury, in New York.

"It is well-designed, his methodology is sound and his conclusions nuanced. His claims are supported and his reservations stated. He is a serious researcher."

Science or politics?

But not everyone is a fan, and Dr. Wintemute has had to dodge his own sort of bullets. He's gotten death threats; one gun manufacturer told him to make sure his insurance premiums were paid. He's struggled to get research grants.

The CDC provided support for some of his early studies. But this funding stream ultimately fell prey to ongoing gun-control debates in Congress.

Some of his detractors are vehement in questioning his motives and his science. Take Timothy Wheeler, MD, a head and neck surgeon in Fontana, Calif.

Dr. Wheeler founded Doctors for Responsible Gun Ownership, a project of the Claremont Institute for the Study of Statesmanship and Political Philosophy, a California think tank, after noticing that prominent medical journals developed what he considers to be a political stance against gun owners.

"They advocated getting rid of guns and enacting laws against law-abiding gun owners," says Dr. Wheeler. "Then they backed it up with advocacy research. ... Wintemute is a good example."

Why? "Garen Wintemute is a gun control ideologue carefully posing as a scientist," he says.

Others are concerned -- not about Dr. Wintemute in particular -- but about the way gun-injury research is often structured. When the studies are conducted only by those known to be anti-firearm, "it raises suspicion of skewed data," says John Malcolm, MD, a pathologist in the Sunbury, Pa., area.

What he would like to see is broad-based data collected by an expert organization, such as the National Highway Safety Foundation.

"I don't have a problem with collecting data on this topic as long as the protocol is not biased to get a result," Dr. Malcolm says. "We would like to see a broad acquisition of data known not to be biased and a proper designing of the study so it is not biased toward obtaining a result."

While many previous studies looked at death, injury and if there was a gun in the house, "there is no data to support that the presence of a firearm had anything to do with the death," he says. "But I think it is important to study if there is a relationship between a gun in the home and an increase in death." With a group like the NHSF that historically collects data on accidental death, the data would be able to stand on its own, he says.

In addition, Dr. Malcolm says there needs to be a group of people to select criteria for the study of firearm injury. "It would be important to include individuals and someone from a big organization that has had a long-term interest in gun safety," says Dr. Malcolm. "Someone from the National Rifle Assn."

Dr. Wintemute takes the barbs in stride. He declined commenting directly about Dr. Wheeler. "I want to prevent gun violence. They think I want to disarm America, and that's not true," he says. "I grew up with guns in the house; I taught marksmanship as a YMCA counselor. ... Our work is about prevention."

These days Dr. Wintemute is working closely with law enforcement and focusing his research on dealers, finding out who sells guns later traced to violent crimes; and he's working on defining characteristics of those dealers associated with crime guns. He and others at the center compile crime and gun injury data. He goes to gun shows. He used to have a gun seller's license. He tells how easy it is to make a straw purchase.

"I have observed cases where the dealer is fully aware [the gun is being bought for someone else] and conducts the sale anyway. I saw a case in which a mother bought a Raven .25-caliber pistol for her son who looked about 15. He picked out the gun; she bought it, gave it to him, and he put it in the baby stroller."

Even so, how does he feel about the future? Optimistic, he says. "It is our job to shine the brightest light we can on conditions."

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 ADDITIONAL INFORMATION: 

Gun stats

• Nearly 40% of American households have guns in them.
• More than 30,000 firearm fatalities occur each year in the United States.
• Approximately three nonfatal gun-related injuries occur for each gun-related death.

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The full report is available at the CDC Web site (http://www.cdc.gov/ncipc/pub-res/epi_of_violence.htm)

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Weblink

Violence Prevention Research Program at the University of California, Davis (http://web.ucdmc.ucdavis.edu/vprp/)

Inaugural address of Richard F. Corlin, MD, AMA president, on gun violence as a public health problem (http://www.ama-assn.org/ama/pub/article/2542-4940.html)

Claremont Institute's Doctors for Responsible Gun Ownership (http://www.claremont.org/1_drgo.cfm)

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