ISIH S3 E14 / Gun Violence in America: The Instrumentality of Guns

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Celine Gounder: Before we start the show today I want to ask you a favor. Don’t worry; it’s easy. This week, I’d like you to tell one person—just one!— about our show. If we can keep growing our audience, we’ll be able to do bigger, more ambitious shows. So please, text or email one friend about the podcast. It would mean a lot. OK, on with the show!

Celine Gounder: Some parts of this episode deal with suicide. Please use discretion when listening.

Ronald Clarke: The key thing is focusing on very specific problems, and trying to understand the opportunity structure for them, and then trying to change that opportunity structure.

Michael Anestis: There's now over 270 million personally owned firearms in the United States right now, more than the next five countries combined.

Franklin Zimring: …guns are five times as likely to kill…

Michael Anestis: …owning a firearm dramatically increases the risk of death by suicide. …these are not debatable points. This is reality.

Celine Gounder: Welcome back to In Sickness and in Health, a podcast about health and social justice. I’m Dr. Celine Gounder. This season we’re looking at gun violence in America.

Celine Gounder: We’re going to start today’s show in Britain. Back in the 1950s. Specifically, the kitchen. Ovens in England and Wales were heated with a gas made from coal.

Your oven has been heating for the last 15 minutes… if you put the sheet in the hottest part, the rolls should be done in 15 min. The gas having been turned fairly high.

Celine Gounder: Any cooking gas is toxic, but this stuff was especially nasty.

Ronald Clarke: If you turned on the gas taps in the oven and put your head inside, you could be dead really quite quickly, like within 20 minutes often.

Celine Gounder: This is how Sylvia Plath famously ended her life. That old line about sticking your head in the oven… that’s what this is about.

Ronald Clarke: Yes, um, various people had observed there was some kind of relationship between levels of suicide and the toxic content of domestic gas pumped into people's homes.

Celine Gounder: This is Ronald Clarke. He’s a professor at Rutgers University. Ronald and his colleague Pat Mayhew got curious about this supposed connection. So, they decided to take a closer look. And they found that gas heating ovens were getting less toxic over time.

Ronald Clarke: …the industry began to make gas from oil. … It was cheaper to make the gases from oil. The toxic content of that gas was considerably less than the gas used previously. Then, even later… after the ovens and fires and all the rest of it in England and Wales were changed to accept natural gas. Natural gas has no carbon monoxide. It's carbon monoxide-free and non-poisonous.

Celine Gounder: As the toxicity of the gas dropped, so did another thing: suicides.

Ronald Clarke: What you see is corresponding declines, very clearly, corresponding declines in the percentage of people in England and Wales who killed themselves with domestic gas. At the beginning of the period I studied, I think it was 1958, the first figures I looked at, almost exactly 50% of people who killed themselves in the country used domestic gas. By the end of the period I studied… hardly anyone at all used gas.

Celine Gounder: Seems obvious, right? The gas is less toxic; fewer people use it to end their lives. But it goes farther than that.

Ronald Clarke: …the interesting thing was that the overall suicide rate in England declined very considerably as well. In other words, people who had been formerly able to use gas, then did not switch to other ways of killing themselves. Whatever the other methods were—handguns, jumping off tall buildings, clambering onto railway tracks, trying to slit their wrists, taking pills—there was partial displacement to these other methods but by no means complete.

Celine Gounder: …most people didn’t look for other ways to end their lives. They just… kept living. Believe it or not, this research has a lot to say about gun violence. Like British oven gas in the 1950s, guns in the U.S. today are cheap, easy to get a hold of, and extremely lethal. That goes for hurting someone else—or yourself.

Celine Gounder: In this episode we’re going to try to apply some of these same lessons to preventing gun-related deaths. How do access, opportunity, and lethality converge to make guns so deadly? In public health and criminology circles, we call this “instrumentality.” How good is a weapon as an instrument of killing? We’ll start with something that seems pretty obvious: guns are lethal.

Celine: When Donald Trump spoke to the NRA in 2018, he talked about knives.... and stabbings… in London.

Donald Trump: I recently read a story that in London, which has unbelievably tough gun laws, a once very prestigious hospital right in the middle, is like a war zone for horrible stabbing wounds. Yes, that’s right. They don’t have guns. They have knives. And instead, there’s blood all over the floors of this hospital.

Celine Gounder: His position was pretty clear: because England regulates guns more strictly, there are more knife attacks. And as a result, he says, people are less safe.

Donald Trump: They say it’s as bad as a military war zone hospital. Knives, knives, knives…

Celine Gounder: This is a common argument from pro-gun advocates. Violent criminals, they say, are going to use any tool at their disposal to commit violence… because that’s what criminals are programmed to do. The same goes for people contemplating suicide. “People kill people,” they’ll say. But this misses the point of instrumentality. Guns are really good at killing people. Knives? Less so. Guns are five times more likely to kill than a knife in an assault. This can have a big impact on how an argument ends.

Celine Gounder: In England, there are more fights and assaults than in the U.S.

Ronald Clarke: Now, that's because of the pub culture in Britain. A lot of assaults in Britain have to do with people who've been drinking in pubs. That culture isn't anywhere near as widespread in this country. So we have more assaults in Britain, but fewer homicides.

Celine Gounder: Fewer homicides because the weapons on hand are a lot less lethal.

Ronald Clarke: If I quarrel with my neighbor in England I can't go and fetch a gun and shoot him, which is quite possible in this country, and we know it happens, but I can't do it in England. I might hit him with my fist… Guns are very, very lethal, and if you have them around, they're more likely to be used in arguments.

Celine Gounder: Just having a gun around can make people more aggressive. Minor arguments can turn deadly. This gets back to this idea of instrumentality.

Ronald Clarke: There's a strong belief generally in the population, this is true in England as well, that the roots of evil lie within people. It's true, but also, situations have a very large effect on outcomes such as homicide and suicide and accidents. Most people are reluctant to see that. They think it's all to do with what's going on in people's minds. It isn't just that. It's also the situations in which they are, and part of the situation is whether there's a weapon available or not.

Celine Gounder: The huge number of guns in the U.S. ups the ante… and makes our crime… a lot more violent.

Franklin Zimring: We used to think that the problem was that we had more thieves than London or Berlin or Rome, and that just wasn't true… in terms of the risk to life that came from criminal violence was not because we had more criminals, but because the offenses committed and the mechanisms that were used were very different.

Celine Gounder: This is Franklin Zimring. He’s a law professor at the University of California-Berkeley. Franklin wrote a book back in the 1990s that took a novel look at crime. He argued that crime and violence weren’t necessarily connected.

Franklin Zimring: Let's go back to the discussions that we were having in the United States, particularly at the beginning of the 1990s. This is the period of the 1994 federal crime legislation. This was the period when half the states in the union passed three strikes laws.

Bill Clinton: When this bill is law, three strikes and you’re out will be the law of the land.

Hillary Clinton: They’re not just gangs of kids anymore. They are often the kinds of kids that are called super predators. No conscience. No empathy.

Franklin Zimring: The notion was that the reason American rates of violence were so high was because we had lots more criminals than other countries. There were two things very much wrong with that analysis. One of them was that it assumed that the way in which you fight life-threatening violence was by locking up anybody that commits crimes, whether violent or not.

Celine Gounder: A quick refresher on robbery vs. burglary. Robbery is when one person tries to take something from another person one-on-one. Burglary is when someone sneaks into your house and takes something when you’re not there.

Celine: OK, back to Franklin.

Franklin Zimring: You lock up burglars because you're afraid robbers will shoot and kill you. Robbers were, in the early 1990s, shooting and killing 1,500 or 1,800 Americans a year. But the problem is, burglars weren't shooting and killing anybody.

Celine Gounder: Franklin compared cases of robbery and burglary in London and New York City.

Franklin Zimring: London had a higher burglary rate than New York City. That must have meant that it had more burglars, but it had a much smaller robbery rate and an infinitesimally smaller armed robbery rate. So that the number of killings from the combination of British property crime—robbery and burglary—was tiny in comparison to the American.

Celine Gounder: So what’s going on here?

Franklin Zimring: The robber’s got to work through you, so you're there, and he has to have something credibly to threaten you—a gun or a knife. Now, why doesn't he, if you say, "No, I'm sorry, I don't have any money"? or if you say, "I'm not going to give you any money," an intelligent armed robber would say, "Oh, the hell with you," and go on and rob somebody else, but that's not what happens. And something like one out of every hundred loaded gun robberies in the cities where we studied them, a killing takes place, and the reason that happens is interpersonal conflict.

Celine Gounder: As we talked about in Episode 13, guns can make people more aggressive.

Franklin Zimring: All of a sudden if you’re refusing to cooperate or otherwise frustrating the robber, even though you two have never met before, you're having an argument. You're having an argument… and you’re having an argument with a man with a loaded gun.

Celine Gounder: Franklin is saying crime doesn’t necessarily have to be violent. It’s the circumstances of the crime that make it deadly.

Franklin Zimring: Gun availability, concealed gun availability, leads to a different mix between burglary and robbery. If you have a gun, robbery seems much easier, and larger gun availability leads to a larger rate of robbery instead of burglary, and, you see, the difference is vast in terms of personal danger. The burglar wants to get to your house when you're not there. That makes it a wonderful way to lose a laptop but not a threat to your life.

Celine Gounder: You’re left with a situation where the opportunity to threaten someone with a gun is greater in the U.S. because it’s so easy to get a gun. And the very presence of a gun in a conflict means the chances of someone dying are much, much higher.

Celine Gounder: Guns are, unsurprisingly, more deadly than knives or other weapons. But what would we find if we just focused on different kinds of guns? Much of the debate on TV news has been about assault rifles, high-capacity magazines, bump stocks and the like. But what makes for the deadliest gun? It depends on how you look at it.

Franklin Zimring: …handguns were traditionally nine times as likely to be used in homicidal events as long guns.

Celine Gounder: And why is that?

Franklin Zimring: Because you can conceal them in public. You cannot, unless it's really raining hard and you're wearing a raincoat, get a very deadly shotgun or rifle through a public sphere without announcing that there is a particularly violence potential and encouraging countermeasures.

Franklin Zimring: And if it's visible, it could lead to control efforts and responses to the presence of a hazard, which is known. But if you've got a pistol in your pocket, the element of surprise makes it very difficult to have an anticipatory response.

Celine Gounder: You were saying handguns are so much more dangerous than say rifles or shotguns because they can be concealed. So why is the focus so much on assault weapons and not handguns?

Franklin Zimring: Because mass shootings get our attention and aggregate statistics less so.

Celine Gounder: Mass shootings are horrific. That’s why they hold our attention. But when we take a step back, handguns are actually the most deadly weapon in the U.S…. at least… by the numbers. More people are killed every year with a handgun. More than shotguns, more than AR-15s… or any other long gun.

Franklin Zimring: …when you go from mass shooting episode to mass shooting episode, you tend to be looking at different issues each time.

Celine Gounder: The way the media covers mass shootings distracts from the bigger problem: the massive number of guns, especially handguns, in this country.

Celine Gounder: Remember the story from the top of the show? The one about detoxifying oven gas in England? We can apply that same thinking to gun-related deaths… including suicides. It’s called “means safety.”

Michael Anestis: Means safety refers to taking a suicide method and making it less deadly or less available for a suicide attempt. That can apply to firearms, so they can apply to any method.

Celine Gounder: This is Mike Anestis. He’s a professor at the University of Southern Mississippi.

Michael Anestis: Means safety is most effective when the method is highly lethal and it's highly popular or frequently used in a specific area.

Celine Gounder: In a sense, means safety is about blunting the “instrumentality” of a weapon.

Michael Anestis: To give us general background on means safety, some classic examples of this were in the 1950s, in the UK by far the most common way to die by suicide was sticking someone's head in the oven. The UK detoxified domestic gas, the suicide rate by sticking your head in the oven went down by 80% to 90%. The overall suicide rate went down by 40%.

Michael Anestis: More recently in Sri Lanka, by far the most common suicide type of method was pesticide. They simply banned some of the most lethal pesticides and the suicide rate in Sri Lanka went down by 50%.

Michael Anestis: And then with firearms, the Israeli Defense Force in the early part of the 2000s realized a lot of their young soldiers who were doing their compulsory military service were dying by shooting themselves on the weekends. They changed their policy and said, "You know what? You can't bring your firearms home on the weekends or for holidays." Their suicide rate among serving soldiers went down by 40%. They didn't start dying on other days. They didn't start dying by other methods. They just stopped dying.

Celine Gounder: There are some parallels here between crime and suicide… do “people kill people?” or do “guns kill people?”

Celine Gounder: Let’s say you have a criminal disposition. Or, in the case of suicide, maybe you’re depressed or have some other mental illness.

Michael Anestis: One of the ways that we've tripped up a bit in the suicide prevention field is that we talked about suicide risk broadly, rather than looking at the difference between risk for thinking about suicide and risk for attempting or dying by suicide.

Michael Anestis: So mental illness, for instance, tells us a lot about thoughts of suicide, but almost nothing about suicidal behavior. There's a huge study called the National Comorbidity Survey that had thousands of participants and they had them fill out information about their suicidal history and their mental illness. … There was no single mental illness, combination of mental illnesses or number of mental illnesses that predicted suicidal behavior…

Michael Anestis: Here's where gun ownership comes in. Gun ownership tells us almost nothing about who's suffering and who's thinking about suicide because guns don't make you suicidal, but they tell us a lot about who's going to die.

Celine Gounder: In other words, it isn’t enough to be suicidal. You need a weapon. A weapon that’s available, accessible and lethal. That sounds a lot… like a gun.

Michael Anestis: The debate between mental health and gun safety is frustrating at multiple levels.

Michael Anestis: …it creates a false choice.

Michael Anestis: When you work towards addressing firearms, it doesn't mean you're not working towards addressing mental health. if you're working towards mental health, it doesn't mean you can't work towards addressing firearms.

Michael Anestis: It's an easy way to pivot away from the gun conversation and to try and paint folks like myself as having an agenda that we don't really have.

Michael Anestis: The quickest, most powerful way would be if there were fewer firearms. If we did not have a country inundated with firearms, our suicide rate would be substantially lower.

Michael Anestis: You have to address the firearm.

Celine Gounder: Franklin Zimring, too, worries that so long as guns, especially handguns, are widely available, it’ll be be hard to make a dent in the gun deaths in America.

Franklin Zimring: …there really are a whole series of rather gentle controls that 80% of the population supports, that when you add them all up, would have a modest at best reduction in the death rate attributable to the use of firearms and violence. That is to say, everything that we're willing to do, even if the NRA didn't exist, is at best a 10% reduction in additional death rate because of the instrumentality effect of all the guns that are out there that get used in interpersonal violence and probably suicide as well.

Celine Gounder: Guns, especially handguns, are unique weapons. They’re widely available… concealable… and lethal. The presence of a gun makes people more aggressive… raises the stakes… and inflames interpersonal conflicts. This is why guns are so deadly… and why it’ll be hard to curb gun-related deaths without addressing the factors that make them so dangerous in the first place… like how easy it is to get one… and how many there are.

Franklin Zimring: Then there are the things that could cut our homicide rate in half, because of instrumentality effects, but those involve very substantial reductions in the availability of concealable firearms.

Celine Gounder: Next episode, we’ll look a country that did just that: Australia. Australia shares a similar colonial history to our own: a foreign land invaded… a wild frontier tamed… and native peoples subjugated. Many still live in rural areas where guns come in handy for everyday work on a farm. They have a strong hunting and sports shooting culture.

But first a scene of horror and carnage in the Tasmanian town of Port Arthur tonight, where as many as twenty-five people have been shot dead in Australia’s worst massacre. At least fifteen people were wounded…

Celine Gounder: And yet… after the Port Arthur massacre in 1996… Australians came to see the need for gun regulation very differently. You’ll hear the story… next time… on “In Sickness and in Health.”

Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Zach Dyer and me. Our theme music is by Allan Vest. Additional music by The Blue Dot Sessions.

Celine Gounder: If you enjoy the show, please email or text a friend about it today. And if you haven’t already done so, please leave us a review on Apple Podcasts. It helps more people find out about the show!

Celine Gounder: You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com. That’s insicknessandinhealthpodcast.com. I’m Dr. Celine Gounder. This is “In Sickness and in Health.”