ISIH S3 E1 / Gun Violence in America: An Unlikely Friendship
Celine Gounder: Welcome back to “In Sickness and in Health,” a podcast about health and social justice. I’m Dr. Celine Gounder. Last season we looked at opioids in America, and the combination of factors—economic, political and cultural—that have fueled an epidemic of drug overdoses and deaths across the nation. This season, we’re going to look at a health problem that may be even harder to disentangle from the non-biological and the non-medical.
Mark Rosenberg: There are a few problems that have been as resistant to scientific solutions as this one. … We're solving the problem of heart disease and heart attacks. We're solving the problems of cancer everyday… but this problem… somehow, it stayed in a problem space by itself. It's devastating. And you might ask "Why did we end up so stuck? What happened? How did we get to this position?"
Celine Gounder: That’s Mark Rosenberg, President and CEO of the Task Force for Global Health. Before that... he worked at the Centers for Disease Control and Prevention... and was the founding director of the National Center for Injury and Prevention Control. Mark’s talking about a health problem that’s gone untreated in America for decades… and it’s one that he’s spent much his career trying to solve: gun violence. And it’s what we’ll be looking at this season. We’re going to travel across the country… and look at the history, politics and culture of guns. We’re going to look at how people get them… what they use them for… and how to make their use… safer for everyone. We’re also going to look at promising interventions, both in the US and abroad. We’re going to see what a public health lens can teach us about how to reduce disease and death from this particular problem. Because in many ways—as you’ll see—gun violence is similar to a lot of public health crises. And in other ways… it is is absolutely not.
Celine Gounder: One of the things that makes gun violence so difficult to address is that it’s almost impossible to study scientifically. Not because the science is too complicated—it’s not. It’s hard because our politics get in the way. That’s what we’re going to look at in this episode. The story starts with the man you heard at the top of the show, Mark Rosenberg. Mark started working at the CDC in 1983, at a time of great change for the organization. When the CDC started, it was focused on infectious diseases like smallpox, tuberculosis and malaria. But by the the second half of the 20th century—as living conditions got cleaner, less crowded and overall better—other diseases were becoming bigger killers in America. By the early 80s, Mark and other researchers had started to realize something:
Mark Rosenberg: It's chronic diseases, like heart disease, cancer, and stroke, and it's injuries, both unintentional injuries like car crashes and drownings, and intentional injuries or violence, like suicide and homicide... This is what people are dying from now.
Celine Gounder: Bill Foege, the Director of the CDC at the time, reorganized the agency around this realization… and he hired Mark to run the newly created Violence Epidemiology branch. It’s beginnings were… humble.
Mark Rosenberg: My office was in the sub-sub-basement of building three. It was a converted men's room. They had taken out all of the urinals and toilets, but they left all the plumbing, so that anytime anywhere in the building where people flushed the toilet, we had to stop talking because you couldn't hear.
Celine Gounder: In 1985, Mark’s boss led a study at the National Academy of Sciences, confirming what folks at the CDC had already observed: the leading cause of death among younger Americans, those under the age of 45 wasn’t disease, like infection, heart attacks or cancer. It was injury. As a result, the federal government created the National Center for Injury Prevention and Control in 1995. It was established as part of the CDC, and Mark was its first director. From the beginning, the National Center for Injury Prevention was controversial.
Mark Rosenberg: The whole question of looking at violence was a hot potato...
Celine Gounder: It might seem counterintuitive—why would studying violence be controversial? Who likes violence? The controversy wasn’t so much about studying violence, but rather, studying how to reduce it. On the left, they were concerned with the potential abuse of people deemed “violent.”
Mark Rosenberg: ...there were a lot of people who were very wary of the government's attempting to intervene in violence… some people saw that there was racial injustice in this, or that it was directed against poor people…
Celine Gounder: But it was advocates on the right who were especially upset and vocal:
Mark Rosenberg: They were… afraid that the aim of the government would be to take their guns away, and for them guns were part of their life, part of their history and part of their culture.
Celine Gounder: Mark’s organization was met with opposition from every direction.
Mark Rosenberg: Violence is the political third rail of American politics, and gun control is the hot center of that storm.
Celine Gounder: Mark knew what he was getting into. But for him, this wasn’t political. Tens of thousands of people were dying from guns each year in America—deaths that could be prevented. And Mark believed that science was key to stopping the problem. After all, science had solved some horrendous problems, both in the United States, they had made big gains on preventing deaths from smoking and heart disease and cancer.
Mark Rosenberg: You got to remember that in… the last century alone… smallpox killed more than 300 million people, and science… had been able to totally eradicate that disease. Wipe it off the face of the earth…
Celine Gounder: Mark’s boss, Bill Foege, was one of the leaders of smallpox eradication. Yeah. Smallpox. He knew better than most the power of science to save lives.
Mark Rosenberg: So science is pretty powerful. It had done things in this country, it had done things around the world, and we thought it was the time to start to apply science to the prevention of gun violence, in a way that wouldn’t be political.
Celine Gounder: Mark Rosenberg and Bill Foege weren’t just thinking about the world’s triumph over smallpox. That same public health approach had produced dramatic results against another public health crisis: car accidents. To experts like Mark—the way we’ve driven down deaths and injuries from motor vehicle accidents—it’s one of the biggest public health successes of the last 50 years. And it has a lot to teach us about how to fight gun violence. You see, before the 1970s, driving cars was incredibly dangerous. Reason number one? Cars… were death traps.
Mark Rosenberg: When I learned to drive, my grandfather taught me on a little red Ford Falcon. And it had a steering column that was a solid piece of steel. And if you had a front end crash, chances were that steering column might... impale you like a spear... and in that front-end collision, the engine block would come into the passenger compartment and crush you like an anvil.
Celine Gounder: And it was more likely you’d get in a crash back then... in the first place. That’s because of reason number two: there was little regulation in terms of age… experience… or alcohol. Combined with the cars of the time… it made for a toxic combination.
Mark Rosenberg: In the 1960s there was an epidemic of young people dying on highways and car crashes. The numbers and the rates were so alarming that the government said we've got to do something about this. They created the National Highway Traffic Safety Administration, and they appropriated 200 million dollars for research.
Celine Gounder: What they found resulted in massive changes to the auto industry.
Mark Rosenberg: Research has produced side impact protection, rollover protection, rear-end protection, seatbelts… front airbags, head airbags, knee airbags, side airbags, so that as a result, people in cars are protected terrifically.
Celine Gounder: They also made us, the drivers, safer.
Mark Rosenberg: We license drivers. We make sure that they know the rules of the road. We make sure that they know how to drive safely. We register cars. We make sure that the cars that are on the road are safe cars that meet the minimal requirements for safety, and we have regulations for the manufacture of cars. We redesigned cars, we redesigned roadways, and we're redesigning drivers. We took off thousands and thousands of intoxicated drivers. And, as a result, I would say, between 1970 and 2012, we have saved over six hundred thousand lives in our country. And, that's a result of research: applying science and changing the way we do things.
Celine Gounder: The auto industry was wary of all these changes at first. But as restrictions and regulations were put into place, it became clear there was a way to make driving safer without lowering the demand for cars or stripping law-abiding citizens of their right to drive.
Mark Rosenberg: And we did all this—we saved hundreds of thousands, more than half a million lives—without banning cars… We don't have to confiscate them... We've found a way to provide an infrastructure that makes driving motor vehicles safer.
Celine Gounder: Mark and his team saw it as a template for how to change gun use. But they knew it was going to be an even tougher issue. Emotions run very high when it comes to gun ownership. Many people think it’s the most fundamental right of all: life or death. But if science could transform driving in America, not to mention eradicate smallpox from the face of the earth, surely it could find solutions for reducing gun violence. Mark was confident his team could do it. What Mark didn’t expect, though, was that he wouldn’t even really get the chance to try. The first real sign of what Mark was up against came in 1993, when the New England Journal of Medicine published an article that linked gun ownership with increased rates of gun violence.
Mark Rosenberg: And what they found was that not only does a gun in your home not make you safer, but the risk that someone in your home will be murdered with a gun goes up 200%—a three-fold increase. And the risk that someone will commit suicide with a gun increases five-fold, 400%.
Celine Gounder: Now to put this in perspective… If someone wants to introduce a new drug and get FDA approval, if the increase in serious side-effects is 20%... it won't be approved. Because that's way too high an increase...
Mark Rosenberg: We're not talking about 20% increase, or 30%, 50% or 100%. We're talking about a 200% increase in gun homicides, and a 400% increase in gun suicides.
Celine Gounder: It was exactly the kind of research Mark Rosenberg hoped to see more of. But to the National Rifle Association... it was a threat to their industry. And unlike Detroit’s automakers... the NRA went into attack mode.
Mark Rosenberg: They wanted to abolish the whole Injury Center to stop the threat, as they saw it, of this gun research.
Celine Gounder: And they found the perfect attack dog.
Jay Dickey: What we’re doing is we are stopping Washington from telling us what we should expect, and we’re telling Washington what we deserve.
Mark Rosenberg: Jay Dickey was the congressman from rural Arkansas. The duck hunting capital of the world. He was an avid duck hunter. He was a born-again Christian, conservative Republican, and a lifelong member of the NRA.
Celine Gounder: Mark first encountered Congressman Dickey at a 1996 congressional budget hearing for the CDC.
Mark Rosenberg: He led off with material that had been provided to him by the NRA.
Jay Dickey: We have here an attempt by the CDC through the NCIPC [National Center for Injury Prevention and Control], a disease control agency of the federal government, to bring about gun control advocacy all over the United States. Through seminars, through the staff members…
Mark Rosenberg: He had quotes that were taken out of context..
Jay Dickey: ...from one of the officials that we pay federal money to: “What we need to try to do is to find a socially acceptable form of gun control.”
Mark Rosenberg: ...they made up things that I had never said and charged me with saying… We were… ambushed.
Jay Dickey: It is a blatant attempt on the part of government to federally fund lobbying and political advocacy.
Mark Rosenberg: When we went back to CDC, my handlers at the CDC said, "Rosenberg, don't you ever go talk to that Congressman." They said it would be like throwing a match on gasoline. They said, “Don't even think about it.” They said, “You got it?” And I said, "Yes, sir. Never, ever talk to that man.”
Celine Gounder: With the help of the NRA, Congress passed the Dickey Amendment, which said the CDC could not “advocate or promote gun control.” Technically the CDC was still allowed to study gun violence. But there was a catch: what if that research showed that restricting or regulating guns would reduce gun violence and save lives? Would that research be promoting gun control? In practice, the Dickey Amendment… had a chilling effect on scientists across the country.
Mark Rosenberg: It said to them, "If you do research in this field, we, in Congress, can come after you. We can write a letter to your boss, whether your boss is a department chair in an academic institution or the president of the university, or whether you're in a government agency… we can write to the Director of the CDC or the Secretary of HHS… And if you do this research, we will write to them and tell them that you were lobbying for gun control, something that is explicitly prohibited." And, so, this was a shot across the bow. It was a warning we could make your lives miserable.
Celine Gounder: Congress also stripped the CDC of the precise amount of funding that had been allocated for research on gun violence.
Mark Rosenberg: These were two shots across the bow.
Celine Gounder: The battle lines were drawn. A few weeks after Mark’s first face-to-face with Jay Dickey...
Mark Rosenberg: We got a request from his staffer, who wanted to discuss some of the data that we had presented at the hearing… And my bosses at CDC said, "Okay, you can go up. You can talk to the staffer, but don't under any circumstances talk to that Congressman." … So I met with the staffer. We met for an hour. He went over the data, and he was really interested in the numbers. He was really interested in what the data showed. And we had a very congenial, cordial conversation. And at the end of that hour, I was ready to go, and he said, "By the way, the Congressman is in his office, and he'd like to say hello to you." I just gulped in, swallowed hard, and I thought, "Oh my God, this is really bad." Either I go and talk to him and get fired, or I stand him up and say, “No, I’m not going to talk to you,” and insult him and make things worse.
Celine Gounder: Mark met with Jay Dickey. But something surprising happened.
Mark Rosenberg: I went into his office, and saw pictures of his kids on all the walls. And we started talking about his kids and his family. He asked me about my kids and my family. And pretty soon, we had spent a while talking, not about gun control, not about politics, but about families. And the next thing I knew, he had invited my son and his whole class to visit Congress.
Celine Gounder: Mark’s son and his class visited the Congressman.
Mark Rosenberg: And I was very touched. I thought that was a very nice thing.
Celine Gounder: Their families got to know each other.
Mark Rosenberg: And then I did something for his daughter. I helped her get a job. I helped him with writing something. We talked again. We talked again. And over time, this southern conservative, arch-Republican, lifelong NRA member, born-again Christian became friends with this curly-haired, liberal, Jewish kid from the northeast, someone that Jay thought was over-educated (and he didn't say it as a compliment)... And though we had started as arch enemies… I mean, really, total enemies, kind of locked in this mortal combat… we started to understand each other, started to like each other, and we learned from each other.
Celine Gounder: Eventually, they did start talking about the issues that first brought them together. And that’s when something really surprising happened. They started to change each other’s minds. Jay Dickey came to appreciate the effect public health research had on reducing automobile accidents and deaths and he saw its potential to save lives from gun violence. And as for Mark...
Mark Rosenberg: Jay helped me see very clearly that… we needed to let people know… we were going to find ways to keep guns out of the hands of convicted felons, but let them stay in the hands of law-abiding American citizens. Jay made it very clear that what we were really searching for was that set of interventions that would both reduce gun violence and protect gun rights.
Celine Gounder: Jay Dickey and Mark Rosenberg’s opinions evolved. While the NRA’s stance only hardened. And the Dickey Amendment and the shrinking of the CDC’s budget for research on gun violence made studying the problem really, really hard.
Mark Rosenberg: The Dickey Amendment and reducing the budget were so effective that after 1999, that after David Satcher left, and when I left CDC, the research on gun violence fell by more than 90%. As a result, we don't know the answers to these basic questions about what works and what doesn't, what's safe and effective and what isn't.
Celine Gounder: For Mark, the final blow came in 1999.
Mark Rosenberg: I was fired. ... I was the person most closely identified with the gun violence research.
Celine Gounder: Mark’s firing had the effect his opponents hoped. It sent a sign to others interested in the issue... that this work could cost you your job.
Mark Rosenberg: And for me, personally, it was very, very painful… If you devote so much time, if you take so much time away from your family and your children to do what you think is an important job to protect people, and then you're fired in a way that was both embarrassing and humiliating… it was really an awful, awful experience.
Celine Gounder: In 2012, Mark Rosenberg and Jay Dickey co-wrote an op-ed in The Washington Post, advocating for the kind of research Mark had been hired to do at the CDC decades ago. In it, they laid out the type of work they thought needed to be done. As Mark explains, that research boils down to asking four main questions.
Mark Rosenberg: The first question was: what's the problem? How many people are killed, where, when, who are they, under what circumstances? What's the relationship between the victim and the perpetrator? … But what’s the problem is the first questions we were trying to ask. The second question was: what are the causes. What's the role of drugs? What's the role of alcohol? What's the role of mental illness? What's the role of domestic violence? What's the role of gangs, of robbery, of easy access to weapons?... The third question we thought to ask is: what works. What works to prevent these deaths? … It requires a rigorous evaluation because you can't figure out in your head if something is going to work or not. And then the fourth question we asked was: once you have an intervention that works how do you apply it? … How do you implement those things that work into policy and law. We said let's use the same type of research. Let's ask the same public health questions for gun violence, and if we start to compile the research, we'll be able to save as many lives or maybe more than we save from motor vehicle crashes.
Celine Gounder: Jay Dickey died in 2017. At the time of his death, he and Mark didn’t share much in the way of politics. But on this they agreed: science could show us how to reduce gun violence and allow for gun ownership. The gun industry, however, continues to spread the idea that you can’t have both.
Mark Rosenberg: What the NRA said is... if you allow the science to go on, it will result in all of you losing all of your guns… The NRA came up with what was for them a brilliant strategy, but what was for the country a devastating and deadly strategy.
Celine Gounder: Mark Rosenberg and Jay Dickey’s relationship was pretty remarkable. A scientist and a politician who genuinely changed each other’s minds. It doesn’t happen much in Washington these days. Especially on an issue ike guns. For anyone who follows politics or watches TV, it’s easy to feel hopeless. But Bill Foege—Mark’s boss at the CDC when he first started—said something that’s stuck with him throughout his career.
Mark Rosenberg: The greatest threat in public health is not violence, it's not HIV/AIDS, it's not Ebola, and it's not the opioid crisis. … "The greatest threat we face is fatalism." It's this idea that here's a problem, and we can't do anything about it. … There are ways to ask and answer the questions, and there's a lot that we can do about it. We don't have to live with it. … And there's a clear road to getting rid of it, and that road follows the path of science.
Celine Gounder: There are solutions. But first, we’ve gotta have hope. We have to believe that there’s a way to balance gun safety and gun rights.
Celine Gounder: In this season, we’re going to see what science can show us about finding that middle ground. We’ll start by looking at the history of guns in America and the different forms gun ownership can take today. We’ll explore how race, gender culture and geography relate. We’ll also look at novel ideas for reducing gun violence. We’ll start with one of the most complicated and seemingly least medical aspects of this crisis: our culture. Next time, on “In Sickness and In Health.”
Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Dan Richards and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com, that’s insicknessandinhealthpodcast.com. If you like what you hear, please leave us a review on Apple Podcasts. It helps more people find out about the show! I’m Dr. Celine Gounder. This is “In Sickness and in Health.”