|Guns and Health|
Jeffrey M. Drazen, M.D., Stephen Morrissey, Ph.D., and Gregory D. Curfman, M.D.
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The Supreme Court has launched the country on a risky epidemiologic experiment. The announcement by the Court last month of its decision in District of Columbia v. Heller,1 which struck down a ban on handgun ownership in the nation's capital, has set the stage for legal challenges to gun regulation in other major American cities. Such challenges have already been introduced in Chicago and San Francisco. If there is a widespread loosening of gun regulations, we will learn over the next few years — in a before-and-after experiment — whether the laws we had in place had a significant impact in mitigating death and injury from handguns. In our opinion, there is little reason to expect an optimistic result; research has shown and logic would dictate that fewer restrictions on handguns will result in a substantial increase in injury and death.
The Supreme Court's 5-to-4 decision reflects the sharp division among the justices and a very narrow victory for the majority. Still, all the justices agreed that American society has a legitimate interest in regulating firearms. The disagreement lay in the extent of regulation that they found acceptable within the framework of the Constitution. The majority indicated that regulation must be limited to specific circumstances, such as gun ownership by felons and the mentally ill and the carrying of firearms in schools and public buildings, whereas the minority believed that more far-ranging regulation, including laws such as the District of Columbia's handgun ban, meets a constitutional standard.
We believe that closer regulation promotes the public health. In April, just after the oral arguments in District of Columbia v. Heller, we wrote that "health care professionals, whose responsibility it is to treat the wounded and the dying, have special reason to be concerned."2 In light of the Court's decision in the case, that concern has been magnified.
The Centers for Disease Control and Prevention, in concert with health authorities across the country, keeps careful records on the number of injuries and deaths that result from handgun use. In 2005, the last year with complete data, there were more than 30,000 deaths and 70,000 nonfatal injuries from firearms.3 About one quarter of the nonfatal injuries and a tenth of the deaths were in children and adolescents. To place these numbers in perspective, 10 times as many Americans die each year from firearms as have died in the Iraq war during the past 5 years. Firearm injuries represent a major public health problem that seems certain to be exacerbated with less handgun regulation.
It is well documented in the medical literature that regulation of guns benefits the public health. For example, a careful study4 demonstrated that the 1976 restrictive handgun law in the District of Columbia, which was the focus of the Heller case, resulted in an immediate decline of approximately 25% in homicides and suicides by firearms, but there was no such decline in adjacent areas that did not have restrictive laws.
With the weakening of handgun regulations, we are very concerned about the health of the public, especially young people, whose safety is disproportionately affected by firearms. We have a heightened concern about suicide, in which impulsivity may have an important role; ready access to a gun may significantly increase the risk of completion.5,6 We believe that a sensible level of regulation is essential. There is no language in the Constitution that would limit regulation. Indeed, the preamble to the Second Amendment includes the phrase "well-regulated" in reference to the use of firearms by militias. Given the diversity of geography and population in the United States, lawmakers throughout the country need the freedom and flexibility to apply gun regulations that are appropriate to their jurisdictions. The Court's decision in District of Columbia v. Heller may greatly reduce the latitude that legislators have had in setting firearm regulations for their localities.
With the Supreme Court's decision and the expectation of a substantial reduction in gun regulation, we are poised to witness another epidemiologic study of the effect of regulation on gun violence. With this experiment, which may play out in many American cities, we will know in the coming years whether the overturned laws reduced death and injury from handguns. The Court has heard the arguments and made its decision; we will now learn the human ramifications of this landmark case.
No potential conflict of interest relevant to this article was reported.
We thank Jordan Eipper for assistance with research.
This article (10.1056/NEJMe0805629) was published at www.nejm.org on July 9, 2008. It will appear in the July 31 issue of the Journal.
District of Columbia v. Heller, No. 07-290 (2007).
Curfman GD, Morrissey S, Drazen JM. Handgun violence, public health, and the law. N Engl J Med 2008;358:1503-1504. [Free Full Text]
Centers for Disease Control and Prevention. Number of deaths from 113 selected causes by age: United States, 2005. (Accessed July 7, 2008, at http://www.disastercenter.com/cdc/Age%20of%20Deaths%20113%20Causes%202005.html.)
Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med 1991;325:1615-1620. [Abstract]
Hemenway D. Private guns, public health. Ann Arbor: University of Michigan Press, 2004.
Miller M, Lippmann SJ, Azrael D, Hemenway D. Household firearm ownership and rates of suicide across the 50 United States. J Trauma 2007;62:1029-1035. [Medline]