The Washington Post Magazine

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That miracle didn't come without a bitter fight, of course. But it's the tobacco model that really shows how the public health approach to firearms injuries could spark a revolution.

Bolstered by the new science of gun violence and taking tobacco and other product liability lawsuits as inspiration, plaintiffs lawyers are eyeing the coffers of gun manufacturers, wondering if they might pry loose millions or even billions of dollars with class action lawsuits that attempt to hold the industry responsible for the violence epidemic. Meanwhile, gun control advocates are reminding one another how radically attitudes and behaviors changed once the surgeon general defined smoking as a health problem. Some are pushing a new regulatory structure that would define guns as dangerous consumer products, heavily restricting their manufacture, distribution and sale.

Banning guns, it must be stressed, is not the stated aim of the scientists doing the public health research. They're trying to save lives, they say again and again, to cut down on firearms-related injuries and deaths, and they don't care how it's done. But there's more than a bit of wishful thinking in the way the tobacco and automobile analogies are deployed. The politics of guns are even more treacherous and complex than the politics of smoking or highway safety, and the American gun lobby – which makes the tobacco and automobile lobbies look mild and accommodating by comparison – is hardly blind to the implications of what it calls "junk science." Change will come, if it does, only after an intense struggle: in scientific journals, in the media, in legislative arenas.

The science of gun violence is still in its infancy, with its most basic principles remaining in doubt. And it would be a huge mistake, to judge from the ferocity of the conflict so far, to think that the "scientific facts" will be left to speak for themselves.

The Apostles of 'Injury Control'
It takes a bit of an evangelist to sell the idea that a previously unsolvable problem can be solved. So it's just as well that Mark Rosenberg, as one co-worker put it, "is not a shy guy."

Rosenberg works out of a bland, beige suburban Atlanta office building that houses the NCIPC, one of the eight "centers" that make up the federal Centers for Disease Control. Along with James Mercy, now an associate director of the NCIPC's Division of Violence Prevention, he's one of the point men in the drive to overthrow the conventional wisdom on guns. Together, they've been pushing the public health approach to violence since the early '80s.

But their work is still invisible to most Americans.

Every time we board a smoke-free airplane or read about a multibillion-dollar tobacco settlement, we're reminded that the culture has repudiated smoking. Every time we buckle our seat belts or strap our children into car seats, we can see how much auto safety has advanced. But nothing comparable has happened on the firearms front, despite almost 20 years of public health research.

Most of us, in fact, don't really know what people in public health do. Especially when it involves something called "injury control."

"Part of the problem is, people don't get it," Rosenberg tells a gathering of public health and safety professionals at 8 a.m. one November morning. "You understand what injury control is – nobody else does. Maybe I exaggerate – there are probably two or three people outside this room who understand."

The room in question is the Washington Ballroom at the Sheraton Washington Hotel, and its bleary-eyed occupants are in town for the NCIPC-sponsored "SafeAmerica" conference. They're here to talk about injury control as it relates to cars, motorcycles, bicycles, baby strollers, falls, fires, drownings, poisonings, sports and playground equipment – as well as firearms. They'll be attending sessions with names like "Using Data to Drive Prevention," "What's New in Injury Surveillance" and "Keeping Kids Safe on the Move." But right now they're getting a refresher course on the four basic questions that define the public health approach to disease and injury prevention, by means of a colorful slide projected on a screen to Rosenberg's left.

"What's the problem?" the slide reads.

"What's the cause?

"What works?

"How do you do it?"

Public health is a can-do culture, and those four pragmatic questions can be applied to a broad range of human woes. Until the late '70s, public health practitioners at the Centers for Disease Control and elsewhere had applied them mainly to disease prevention. Then, in 1978, "there was a report for the director of CDC that basically led to the diversification of CDC," Rosenberg says. "And it said, let's look at what people are actually dying from in this country."

When they did, the role of injuries stood out. More years of future work life, it turned out, were being lost to injuries than to cancer and heart disease combined. Within the injury category, motor vehicle crashes were the leading cause of death. Gunshot wounds ranked second: In 1977, they killed roughly 31,000 Americans, a total that included 16,000 suicides, 12,900 homicides and 2,000 accidental shootings.

By 1985, the National Academy of Sciences was calling for a centralized, coordinated public health effort directed at all kinds of injuries and suggesting the CDC as the logical place for it. Mark Rosenberg – a CDC epidemiologist who had worked on diarrheal diseases, among other things, before he got into injury work – was chosen to head the new division that resulted.

The CDC's firearms work focused on collecting better basic data, then starting to look at possible "risk factors" for gun violence, the factors that made such violence most likely to occur. Its resources in this area were still extremely modest – gun research would never amount to more than 5 percent of the agency's injury control budget – but within its limited means, it was leading the scientific charge. It produced in-house research. It supported the work of university-based researchers. And it started giving grants to states to fund basic data collection at the local level. Among the recipients was Maryland's Firearm-Related Injury Surveillance System, which brought in Brian Wiersema and two other University of Maryland criminologists as collaborators.

At the same time, other public health types were thinking ahead to the "what works" stage.

In Baltimore, Stephen Teret and two Johns Hopkins colleagues put forth a "life cycle" theory of guns. Their focus on gun manufacturing attracted a student named Garen Wintemute, an emergency room physician from Northern California who would go on to write Ring of Fire, a revealing portrait of the six manufacturers clustered around Los Angeles that "dominate the production of easily concealable, inexpensive handguns." Wintemute sought through this work to increase legislative and legal scrutiny of these weapons.

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