Saturday, December 15, 2012

The Epidemiology of Senseless Agony

Like millions of other Americans did yesterday, I listened to the news of the tragedy in the Sandy Hook neighborhood of Newtown, Connecticut while my emotions rapidly oscillated between fear, anxiety and outrage. I spent most of the day seeing patients in the hospital and so was only vaguely aware that something terrible had happened. I got into my car in the early evening and soaked in what details were known as I made my way on the hour long commute into Boston where we were having dinner with some friends. I walked into the door, found my child, and held him while I wept.

Surely that scene must have played out in countless homes across the United States yesterday--private moments of utter grief as we contemplate the suffering that must be taking place for the families of those children and teachers in Connecticut. So too are the numerous public expressions of shock and horror that could be found on Facebook or Twitter. Everyone wants to express something of the peculiar emotional state in which we find ourselves after yet another mass killing of people whom we do not know but whose lives very much resemble our own. And so we have, and it is very nearly unbearable to read a Facebook news feed today.

I am no different in wanting to say something to help process my own sorrow, and the words I can summon have already been used by tens of thousands of others: unspeakable and unthinkable and horrific and on and on. But Sandy Hook can also be described in different terms besides moral outrage, and one term in particular leapt to mind because I am a physician and because I treat infectious diseases.

Sandy Hook is part of an ongoing epidemic.

It is an epidemic in every traditional sense of the term: it affects "many persons at the same time, and spreads from person to person in a locality where the disease is not prevalent", as describes it. It is prevalent, and it is widespread. It is, in a very meaningful way, a disease that continues to afflict our country, and will continue to reach new communities unless it is stopped.

For Sandy Hook is, as everyone knows, not an isolated incident, but rather simply the latest in a string of horrors that began its modern phase with the Columbine massacre in 1999 and has included the Virginia Tech massacre in 2007 and this year's repeat performance in Colorado at a movie theater in Aurora. Like, say, HIV, where strange isolated cases cropped up decades before the full-scale epidemic began in the 1980s, almost serving as a warning of things to come, mass shootings also have much earlier precedents, the most famous being the University of Texas shootings in 1966 and, more obscurely, the Bath School incident in 1927 (which was for the most part a bombing rather than a shooting). Since Columbine, however, we've witnessed a steady stream of mass death.

Against the backdrop of these earthquakes of violence are what might be thought of as tremors of shooting--dozens of one- or two-person killing events that would hardly garner a blip on national news coverage today, so desensitized have we become to gun violence that mere individual shootings do not merit our attention or alarm. (The Wikipedia link only deals with school shootings: actual gun violence in the United States currently accounts for over 30,000 deaths per year, which is roughly the same number of people that die of influenza on average in any given year.)

From an epidemiologic perspective, gun violence precisely resembles any number of lethal infectious diseases. And like other infectious diseases, it will not abate simply of its own volition, our expressions of rage and grief notwithstanding. No amount of candlelight vigils or eloquent statements from public officials will put a dent in this problem. We'll see another Sandy Hook, and we'll probably see it again within the next year or two if this behaves like any other uncontrolled epidemic.

So what will make a difference?

I think it's helpful again to look at how we treat infectious epidemics. Over the past several months there has been a very deadly multistate meningitis outbreak; 37 people--almost exactly the number of the Aurora and Sandy Hook casualties combined--have died thus far. And the response of our government has been swift and definitive. The company which was the source of the outbreak was quickly investigated and shut down, as were other pharmacies who were immediately inspected as well. The FDA, CDC and various state health authorities worked in close coordination. And as a consequence of a government that functions to protect its citizens, the outbreak appears to be under control. Should we expect less of our government to address the problem that led to Sandy Hook?

Yet the epidemic of gun violence, which is a far more serious and prevalent problem in the United States, remains "untreated". Indeed, even initiating a discussion about how such a treatment should be administered can cause fierce recriminations. Only a week ago, sports journalist Bob Costas opined in his typically erudite fashion that the Jovan Belcher tragedy might not have happened at all had it not been for Belcher's possession of a gun; the roar of the right wing could be heard immediately. Even the President's statement about Sandy Hook, while unquestionably tactful, was extremely cautious on the subject of gun access. No such caution would have been in evidence had he been speaking about a case of Ebola.

As someone who knows something about how infections and epidemics behave, I'm confident that if we don't change the way we understand an unregulated gun culture, Sandy Hook won't be the last victims this disease will claim.


  1. Medical doctors have written about gun violence as epidemic before (including a pre-and-post-test of D.C.'s strict gun law), and other than the Brady Law respite, have had no effect on public policy. This event provides another tragic opportunity to bring scientific reason into a political debate. An unfortunate side effect will be schools spending many millions of dollars on "security" when the school administrators have no knowledge of even common-sense precautions.

    -Friend of blogger and criminal justice professional.

  2. Thanks, Friend. It's true that I am hardly the first to describe gun violence as an epidemic. Yet the more people describe it as just that--comparing it to other public health menaces about which we actually, you know, do preventative stuff--they might start to get the idea that there are some fixes for it and not see it as this issue of morality where "bad stuff happens", which is really just an excuse to live with the status quo. Best, Billy

  3. I totally agree with you, but you gotta be careful with your numbers. Roughly 2/3 of the 30,000 cases are suicides. Those are tragic, but not quite relevant to the discussion of gun control.

    1. Why on earth not? Compare our (successful) suicide rate with that of countries that have banned guns--including handguns, which are designed to kill individual human beings at close range.

      Re: Billy Rubin's response below: there are as many guns in Canadian homes as in ours: rate of ownership is more or less identical (though murder rates are very different). So I'm not surprised that Canada's suicide rate is only slightly lower than ours.

      (I'm not the same Anonymous btw as the one I'm responding to!)

    2. Thank you, Second Anon, for your thoughts. Weird thing about Canada is that while both gun ownership and suicide rate may resemble that of the US, total per capita death by firearm is less than half that of ours (4.8 vs. 10.2 per 100K): I dunno how to interpret those numbers at first blush, except that it would seem to lend credence to my hypothesis that the suicide rate in South Korea would be considerably higher if South Koreans had easier access to guns. Best, Billy

  4. Anon, you are quite right: in the most recent year for which the CDC has complete information, the total number of firearm homicides is 11,493 ( while the total number of firearm suicides is 18,735 (, which is just under 62 percent of the total. I should have drilled down a bit more when checking my stats, and appreciate your correction.

    That said, I am not completely convinced that introducing firearm suicide statistics is not quite relevant to the discussion of gun control. Lots and lots of people have blue days in their lives where easy outs can seem tempting. It's much, much easier to act in such a state when a gun happens to be handy.

    For instance, I'm not sure what to make out of this set of data showing suicide rates per capita by country ( Canada, the country that most closely resembles the US, has virtually the same rate per 100,000 (12.0 in the US vs. 11.3 in Canada, both countries being in the middle of the pack). The two countries that I would think of as being most like the US after that (the UK and France) are much lower (UK rate about half of US) as well as higher (France's rate is 15.0 per 100K). How would an unrestricted gun culture affect those countries? Hard to say given other cultural differences. So, take my very non data-based guess for what it's worth, but I suspect that the suicide rate in pressure-packed South Korea (the second highest in the world and nearly triple that of the US) would go up, maybe way up, if clinically depressed Koreans--the kind of people who would find throwing themselves off a bridge unpalatable--had easy access to what would seem like a quick and reasonably painless exit from the world.

    Best, Billy

  5. Suicide must be counted amongst the casualties.

  6. Julie votes with me! She was not bribed, largely because I don't have a paypal account in which to deposit money in her name.--Billy