Health Affairs, 23, no. 4 (2004): 280-281 doi: 10.1377/hlthaff.23.4.280 © 2004 by Project HOPE	New Online   How Would Obama, McCain Cover The Uninsured?   Debating Cost Of Uninsured   Try Medicare-For-All   HA Blog Top 10

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Book Reviews

Prevention Before Blame

In 2001, the most recent year for which data are available, 29,573 people in the United States died of gunshot wounds. There is good news in this number: 29,573 is a substantial drop from a high of 39,595 fatal gunshot wounds in 1993. Nevertheless, each week nearly 600 U.S. families make funeral preparations for a loved one who was killed with a firearm. Most of these deaths, contrary to popular perception, are suicides—16,869, or 57 percent of all fatal gunshot wounds, in 2001. Relatively few—802, or less than 3 percent of all fatal gunshot wounds in 2001—are unintentional.

Until recently, assault-related shootings were perceived solely as the purview of law enforcement; self-directed shootings were thought of as a mental health issue only; and unintentional shootings were considered an accident, a random event that little could have been done to prevent. In addition, research on homicide and suicide focused largely on risk factors associated with becoming a victim or perpetrator—in other words, on the individuals on either end of the weapon. Enter public health. Ripe with successes as diverse as eradicating smallpox to reducing injuries from motor vehicle crashes, a handful of public health researchers and practitioners began to view firearm-related injuries, regardless of who pulled the trigger or why, as being preventable.

In Private Guns, Public Health, author David Hemenway is not the only, or the first, scholar to draw comparisons between public health approaches to motor vehicles and firearms or to cigarettes and firearms. His book, however, is the first comprehensive exposition on public health approaches to the injuries, both fatal and nonfatal, associated with firearms.

Private Guns, Public Health is a quick and easy read—a sign of a well-written manuscript. When the reader is someone who knows a bit about the topic, it is also the mark of accurate writing. Interspersing dispassionate critiques of population-based research with news bulletins about individuals, the book is accessible, almost conversational, without sacrificing accuracy or precision. The ability to communicate clearly and concisely is a hallmark of a good teacher, and Hemenway’s classroom skills—he has won the Golden Apple Award for teaching more than a dozen times from students at the Harvard School of Public Health—shine through. The writing pulls in the reader and does not lose momentum. The decision to put more detailed, sometimes technical, information in appendices also helps in this regard.

Hemenway covers a range of topics as he describes how public health approaches seek to prevent injury rather than to find the appropriate locus of blame. After reviewing the epidemiology of firearm-related injury and death and how and where guns are kept and carried, Hemenway addresses research that has been widely cited in policy debates and concludes that the evidence for less-restrictive policies is weak. He examines estimates of using a gun in self-defense and generally finds them to be overstated. He also takes on research about gun carrying; he carefully and dispassionately eviscerates the research that concludes that more permissive laws about carrying concealed weapons will reduce crime. In addition, he includes information about specific demographic groups that is likely to be of interest to the general reader—for example, blacks are less likely to own guns and more likely to support gun control.

Hemenway’s training as an economist comes through in his chapter entitled simply "Supply," in which he addresses manufacturers, licensed dealers, and the unregulated market. Several chapters address policy considerations—the cultural and Constitutional context of firearm policy making in the United States, public opinion, and lessons from other products and other nations. The book closes with a rapid presentation of many ideas for policies that could reduce firearm injuries, a number of which, perhaps surprising to some, have nothing directly to do with guns (for example, preventing and treating depression and reducing alcohol and drug problems).

The book focuses primarily on the United States, which is understandable given the magnitude of the firearm injury problem in the nation. Recent efforts (for example, the United Nations’ work in small arms and light weapons) document the problem that firearms present to health, especially in developing countries. Additional research and another book will be needed to address firearms injury on an international scale.

Other books address additional aspects of U.S. firearm policy making: for example, Gun Violence, the Real Costs, by economists Philip Cook and Jens Ludwig; and Shots in the Dark, by former ATF special agent William Vizzard, which describes the culture in which firearm policy is made. Even if other books come along, Hemenway’s Private Guns, Public Health will continue to be a valuable resource for policy-makers, advocates, students, and others who want to understand public health approaches to reducing fatal and nonfatal injuries from gunshot wounds.

Hemenway describes himself as neither pro-gun nor anti-gun; his passion is for health. This is no small consideration given current sensitivities about firearms and funding for research on firearm-related injuries. In 1996, the National Rifle Association successfully lobbied Congress to rescind the $2.6 million of the Centers for Disease Control and Prevention (CDC) budget that was, at that time, allocated to studying injuries from firearms. The CDC has—in the perception of some, including my own—been reluctant since then, and perhaps understandably so, to fund investigator-initiated research on firearms and has put distance between itself and firearms-related studies. Hemenway, director of two CDC-funded injury prevention centers, makes it explicit that his book was an effort independent of the federal agency: "No CDC money has been used to support any portion of this book. This book was funded entirely by grants to the author from two private foundations, the Robert Wood Johnson Foundation and the Open Society Institute."

Within this politically charged environment, Hemenway has sifted through a mountain of research to create a clear and concise description of public health approaches to gun-related injuries. "Hemenway carefully and dispassionately eviscerates the research that concludes that more permissive laws about carrying concealed weapons will reduce crime."

Susan B. Sorenson

Editor's Notes

Susan Sorenson is a professor at the University of California, Los Angeles, School of Public Health.

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