The n e w e ng l a n d j o u r na l of m e dic i n e

Edi t or i a l s

Rooting Out Gun Violence

Debra Malina, Ph.D., Stephen Morrissey, Ph.D., EdwardW. Campion, M.D.,
MaryBeth Hamel, M.D., M.P.H., and JeffreyM. Drazen, M.D.

Here we are again. Less than a year ago, an edi- have acted effectively to stop them.4 If any other
torial in the Journal by Kassirer reexamined the public health menace were consistently killing
massive public health problem of gun violence in and maiming so many Americans, without re-
the United States,1 and a Perspective article by search, recommendations, and action by the CDC,
Sacks, born of a personal tragedy, lamented the the public would be outraged.
defunding of research on firearm-injury preven- But in the United States, the National Rifle
tion.2 Kassirer called for electing lawmakers at Association (NRA), the legislators it has funded,
all levels of government with the courage to and a certain breed of gun owners have stood in
defy gun lobbyists, so that essential regulatory the way even of research to determine what
changes can finally be enacted as physicians, policies might help. The single or double gun
public health experts, and others have been rec- deaths that go on around us every day rarely
ommending for decades. But in early Decem- evoke any public response, and the predictable
ber, the day after a young couple turned up at reflex response to the louder mass shootings,
a holiday party in San Bernardino, California, after exhortations to pray for the victims, takes
with semiautomatic weapons and went on a two forms: calls for reviving research and calls
shooting rampage, killing 14 people and injur- for improving mental health care.
ing 21, Congress voted down a measure that No doubt both of these avenues are important
would have prevented people on the terrorist to pursue. Though the research pathway often
watch list from getting guns and stalled on a feels like a delaying tactic doomed to encounter
measure to enhance background checks.3 An the same barriers that efforts to change laws
existing federal ban on military-style assault face, House Democrats did on December 10 in-
weapons, which ought to be an uncontrover- sert into an omnibus funding bill a provision
sial, if inadequate, first step, was allowed to lifting the ban on federal funding for gun-vio-
lapse in 2004. lence research. While the mental health care
In 2013, the latest year for which the Centers pathway, for its part, could have broader bene-
for Disease Control and Prevention (CDC) has fits, it would, at best, solve a tiny fraction of the
data, more than 33,000 people in the United problem 3 to 5%, says Friedman, noting that
States died from gunshot injuries and more than most people who are violent are not mentally
84,000 survived with such injuries, many of ill, and most people who are mentally ill are not
them requiring ongoing care for both physical violent.5 It also seems to make mental health
and mental health. After this years high-profile workers or primary care physicians responsible
events in San Bernardino, Colorado Springs, for the impossible task of diagnosing and treat-
Charleston, and Roseburg, Oregon, commenta- ing anyone who might conceivably start shooting
tors once again marveled at the vast gap between people.
U.S. rates of gun deaths and those in other de- Most important, neither of these responses
veloped countries, which either have never wit- gets at the root of the problem. Something in
nessed the epidemic of gun violence and the kind the psychological or sociological makeup of the
of mass shootings that are now routine here or United States has left us at this long-standing

n engl j med 374;2nejm.org January 14, 2016 175

The New England Journal of Medicine
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 The n e w e ng l a n d j o u r na l of m e dic i n e

impasse. Gun-control advocates blame the NRA, not be able to diminish its power. Too many
but perhaps the NRA is less like a foreign patho- Americans will continue to get their hands on
gen that has invaded our body politic, to which assault weapons, too many will kill or maim
we could mount an immune response, than like other Americans, and we will continue to bicker
a cancer, growing from our own mutated cells. about whether the first step is more research or
And that dangerous mutation seems to be a sad better mental health care while we continue
distortion of the American principle of individu- to do nothing to cure the disease.
alism that prioritizes ones right to live the way Disclosure forms provided by the authors are available with
one wants, without any government interference, the full text of this article at NEJM.org.

over other peoples right to live at all a distor- This article was published on December 16, 2015, at NEJM.org.
tion that has found one of its key expressions in
firearm-related freedoms. But gun violence is an 1. Kassirer JP. Guns, society, and medicine. N Engl J Med 2015;
372:874-5.
assault on the health of the public. An equally 2. Sacks CA. In memory of Daniel reviving research to pre-
fundamental American principle holds that en- vent gun violence. N Engl J Med 2015;372:800-1.
suring the public health sometimes requires curb- 3. Steinhauer J. Mass shootings stoke ideological fighting in
Congress. New York Times. December 3, 2015 (www.nytimes.com/
ing the rights of individuals in order to benefit 2015/12/04/us/politics/congress-shifts-attention-to-americas-role
and protect the community as a whole. -in-the-world.html?_r=0).
Previous commentators including Hemenway 4. Quealy K, Sanger-Katz M. In other countries, youre as likely
to be killed by a falling object as by a gun. The Upshot. December
and Miller have listed among the steps toward 4, 2015 (www.nytimes.com/2015/12/05/upshot/in-other-countries
reducing gun violence changing social norms.6 -youre-as-likely-to-be-killed-by-a-falling-object-as-a-gun.html).
Given that it requires deep cultural changes,1 5. Friedman RA. Violence and mental illness how strong is
the link? N Engl J Med 2006;355:2064-6.
however, that is far easier said than done it 6. Hemenway D, Miller M. Public health approach to the pre-
is, as Wintemute has argued, the work of gen- vention of gun violence. N Engl J Med 2013;368:2033-5.
erations.7 But it is work that we need to begin. 7. Wintemute GJ. Tragedys legacy. N Engl J Med 2013;368:397-9.

If we never address the underlying beliefs that DOI: 10.1056/NEJMe1515975

sustain this guns-everywhere extremism, we will Copyright 2015 Massachusetts Medical Society.

Califf for the FDA

JeffreyM. Drazen, M.D.

Robert M. Califf, M.D., has been nominated to world; and until his FDA nomination, his tenure
be the next head of the Food and Drug Admin- as head of the Duke Translational Medicine In-
istration (FDA); he currently serves as Deputy stitute and professor of medicine at Duke Uni-
Commissioner for the Office of Medical Prod- versity. Over his 30-year academic career, he has
ucts and Tobacco. We think his confirmation as published more than 1200 peer-reviewed publi-
commissioner should proceed as quickly as pos- cations, work he has authored has been cited
sible. Because the FDA oversees the safety and, over 50,000 times, and his Web of Science h-index
in some spheres, the efficacy of products that is 118. But academic output has not been his
constitute about 25% of our economy, the coun- primary goal; instead, he has worked to accrue
try needs a strong and experienced leader who the data needed to improve patient care. Despite
can keep the FDA focused on its mission. this laudable aim, a few concerns have been
Since Califf was nominated to succeed Mar- expressed about his associations with industry,
garet Hamburg, numerous individuals and groups and these concerns may have caused some to
have endorsed his candidacy.1-3 His noted withhold support for his nomination.4-6
strengths include his experience in the testing of Like Califf, we believe that our actions should
new and established drugs for efficacy; his suc- be driven by data, not innuendo. Since 2005,
cessful career at Duke University, where he was Califf has reported, as an investigator, the out-
the founding director of the Duke Clinical Re- comes of seven clinical trials sponsored solely by
search Institute, by many measures one of the industry in primary publications in major gen-
premier academic research organizations in the eral medical journals.7-13 Of these trials, four had

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The New England Journal of Medicine

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