Chapter 2. The Public Health Approach
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Chapter 2  The Public Health Approach Assaultive injuries have been subjected to little prevention oriented research. Typically they have been regarded as a crime problem rather than as a health problem and blame and punishment of the perpetrators have been emphasized rather than measures to reduce the frequency and severity of such injuries. —Institute of Medicine, 1985 During most of the twentieth century, gun assaults were seen almost exclusively as a criminal justice problem, gun suicides as a mental health problem, and unintentional gunshot wounds as a safety issue. Since the mid-1980s, it has become increasingly recognized that the most promising approach to reduce firearm injury is to emphasize prevention, focus on the community, use a broad array of policies, and bring together diverse interest groups. This approach is proactive rather than reactive, is pragmatic rather than doctrinaire , and has a distinguished history of success in addressing problems that affect the public’s health—it is what I refer to throughout this book as the public health approach. This chapter describes the public health approach to reducing the firearm injury problem in the United States and the history and scientific basis of injury prevention and control as a public health field (Hemenway 1995). The chapter also contrasts the public health approach with the gun advocates’ dichotomous view of a world inhabited solely by “good guys” and “bad guys” and explains why the public health perspective leads to more effective policy prescriptions. What Public Health Means in Practice The proactive, community-oriented approach of public health can be contrasted to the often reactive, individual focus of therapeutic medicine and tra8 the public health approach 9 ditional criminal justice. Medicine’s principal focus is on curing the individual patient, one person at a time. Medical care providers across the country treat gunshot victims and their families on a daily basis, usually in humane and often heroic ways, but they do so one patient at a time. Similarly, the law enforcement and criminal justice systems seek to apprehend and punish those committing crimes, one perpetrator at a time. Although deterrence is an important goal of the criminal justice and tort systems and prevention is increasingly seen as a police function, most of the activity still takes place after the fact. By contrast, the goal of public health is neither to determine fault nor to punish perpetrators. Instead, public health focuses directly on prevention—eliminating the problem before something bad happens. The scientific core of public health is epidemiology, which identifies the risk factors, trends, and causes of health problems. But sound science is the starting point, not the end point, of the public health approach. Rallying political and social support around solutions is the way public health has achieved many of its goals. Perhaps the most important public health advance of the nineteenth century was the “great sanitary awakening” (Winslow 1923), which identified filth as both a cause of disease and a vehicle of transmission. Sanitation changed the way society thought about health. Illness came to be seen as an indicator not of poor moral and spiritual conditions but of poor environmental conditions . Public health interventions began to emphasize the need to change the environment as well as individual behavior. Early efforts to combat tuberculosis, for example, succeeded primarily because they addressed poor sanitation and overcrowding in urban neighborhoods rather than because of individual medical treatments (Haines 1997). The knowledge that social and environmental conditions could cause disease and the identification of societal actions that could dramatically reduce outbreaks meant that health could no longer be considered solely an individual responsibility. Public health came into its own. In the United States, gun violence is a modern-day public health epidemic. Preventing gun violence requires not only individual (e.g., parental) accountability but also collective responsibility. Generating support for collective efforts to reduce gun violence is a current challenge for public health. Although most of the improvement in the health of the American people (e.g., a rise in life expectancy from forty-seven years in 1900 to seventy-six years in 1990) has been accomplished through public health measures rather than direct medical advances (Evans, Barer, and Marmor 1994), beneficiaries often do not recognize that they have been helped. This is one reason why public health, to succeed, must rally political and social support for collective as well as individual responsibility. While the medical and criminal justice communities deal with identifiable people in identifiable ways, the benefits of public health interventions usually...