Why Should Doctors Ask Patients About Guns? Here’s Why.

Over a period of three days in June 2014, an agitated and obviously extremely upset young man named Christopher Hampton showed up seven times at hospitals in Fargo, ND, claiming that his roommate, who was also his cousin, was trying to poison him.  During one of the visits, Hampton was tested for poisons in his system but the tests showed only traces of marijuana and amphetamines.  He was told on several of these visits to seek psychiatric care but was not considered to be a danger to himself or anyone else.

On June 26, shortly following his last encounter with medical practitioners, Hampton went back to his apartment, grabbed a gun and shot his cousin to death.  At his trial, which is going on right now, Hampton had obviously regained his composure to the point that he was claiming self-defense and may testify that a series of arguments led up to a serious fracas in which he was victim, not assailant, and had no choice but to defend himself with a gun.  But the last witness to testify for the prosecution was a pathologist, Dr. Mark Kaponen, who noted that the entry wounds were in the back of the victim’s head, which is a pretty interesting way to shoot someone if you’re using a gun in self-defense.

docs versus glocks                The way things are going, it looks like there will be somewhere between 11,000 and 12,000 homicides committed this year with a gun.  And most of these shootings will involve perpetrators and victims who not only knew each other, but had been engaged in an argument or a series of arguments for hours, days or weeks leading up to the fatal event.   As Dr. Lester  Adelson put it in a classic article: “With its peculiar lethality, a gun converts a spat into a slaying and a quarrel into a killing.”  I actually prefer Walter Mosley’s more prosaic statement:  “If you carry a gun, it’s bound to go off sooner or later.”  Either way, the bottom line is that what we have in the Fargo homicide is a classic mixture of drugs, an argument and a gun.

But there was something else about this case that needs to be addressed and understood.  The fact is that the shooter, Christopher Hampton, certainly tried to draw attention to himself in the days leading up to the tragic event.  He visited health facilities six or seven times, he made it clear that he was concerned about his own welfare and safety, he may have made some pretty nutty statements about his cousin, but that was exactly the point.  People who walk into a medical facility under their own free will and say crazy, delusional things need to be taken seriously, not just told to ‘go home and relax.’ In fact, Hampton had previously been diagnosed as having bipolar disorder but stated that he had stopped taking his prescribed meds. How many red flags did this young man need to wave?

In fact, he waved one more, the reddest flag of all, because he told a cop just before the shooting that there were guns in the apartment and asked the cop to take them away.  The police officer decided there was no criminal activity going on and declined Hampton’s request to seize the guns. Two hours later, Hampton shot his cousin to death.

According to the NRA, there’s no reason for physicians to even ask patients about gun ownership unless the patient poses a clear health risk.  But how does a clinician know that a patient has stepped across that line?  How could anyone know for sure that Christopher Hampton’s delusional behavior would lead to a life-ending event?  The point is we don’t know, which is why doctors need the widest possible latitude in asking questions about the presence and use of guns.  And anyone who truly believes that physicians should not be concerned about guns is as delusional as Christopher Hampton the night he ended his cousin’s life.


Do We Understand Gun Violence? Not Yet.

Yesterday a very important article appeared in the Annals of Internal Medicine that once again appears to demonstrate a strong link between homicide and suicide rates and availability of firearms.  The authors, led by Andrew Anglemyer of the University of California, San Francisco, conducted an extensive search of all relevant published and unpublished studies, compared, synthesized and correlated results and confirmed that access to firearms “is associated with risk for completed suicide and being the victim of homicide.”

This is not a new piece of news for the public health community, although it will be viewed with suspicion and distrust by groups like the NRA that view everything about guns produced by public health researchers with suspicion and distrust.  Research on links between guns and violence directed either outward or inward has been going on since the early 1990’s and the results always seem to be the same.  To quote my favorite authority on the subject of gun violence, the author Walter Mosley, “If you carry a gun, it’s bound to go off sooner or later.”

Union St., Springfield, MA

Union St., Springfield, MA

But now that we have exhaustively shown when the gun will go off, either in a homicide or a suicide, the problem still remains to figure out the why.  Because even though 30,000 gun homicides and suicides is a big number, let’s not forget that there are some 35 million homes where guns can be found, which means that somewhere around 90 million people have access to those guns, which means that roughly 89,970,000 Americans who could have used a gun to commit a homicide or a suicide chose not to do so.

What we usually do is to figure out where the people live who use guns to hurt themselves or others, and once we figure that out, then we try to identify the users themselves.  Which is easy to do in the case of suicides, because the shooter and the victim are both lying there on the floor.  It’s less easy to figure out in the case of homicides, where a police department that makes an arrest in more than one out of every two homicides is doing a pretty good job.   What we don’t seem to do is what David Hemenway calls the “individual-level studies of perpetrators;” in other words, why do certain people carry and use guns?”

The answer tends to focus on what Hemenway calls “ecological” studies which make connections between gun violence and the socio-economic factors that create environments in which high levels of gun violence occur.  And we now know that if we look at a community or a neighborhood with high rates of violence and gun homicide, we can usually also find high rates of unemployment, family dysfunction, educational underachievement and the usual list of inner-city ills.

With all due respect to this scholarship however, and I have nothing but admiration for the many dedicated researchers who have been studying this problem for, lo these many years, I also think they are ignoring one important point.  The multi-family dwelling pictured above is the location in Springfield, MA, of at least three and possibly four homicides over the last 19 months.  The area within one-quarter mile of this address contains every facility and resource that the 4,000 residents of that area ever use: school, church, hospital, community center, police station, playground, supermarket, deli and fast foods.

The city of Springfield had 25 homicides over the last 19 months and 4 of them happened here.  Springfield had a homicide rate per 100,000 of 12 – three times the national average – but this street had a homicide rate of 50 per 100,000.  And they didn’t all happen in one day.  They were spread out over 19 months and the most recent occurred last week.

I wouldn’t be surprised if what goes on in front of 435 Union Street in Springfield is what goes on in every city where high levels of gun homicides take place.   It’s not just about the demographics of the inner city, because even on bloody Union Street 3,996 of the 4,000 neighborhood residents haven’t found a reason to pull out a gun. Hemenway is correct when he calls for individual-level studies of shooters, but some way will have to be found to study them one at a time.


Want To Avoid Getting Shot? Stay Away From Where The Shootings Occur

Lotka-Volterra equation

Lotka-Volterra equation

You don’t need to be a rocket scientist to figure out that what the novelist Walter Mosley said about guns is true: “If you carry a gun, it’s bound to go off sooner or later.”  Which is kind of obvious because after all, if you don’t carry a gun it can’t go off, right? But the trick, if you’re concerned about gun violence, is figuring out when and why a gun goes off, and once you know that, what to do about it. We seem to be much better at figuring out the when and the why, but an article published yesterday in the Journal of Public Health, may point a way towards also figuring out the what.

The authors, two Yale sociologists, Andrew Papachristos and Christopher Wildeman, have constructed a model for predicting gun violence based on studying gun homicides from 2006 to 2011 in an area of Chicago that had some of the highest rates of gun violence in a city that’s know for gun violence.  The study found that 6% of the area’s population was involved in 70% of the murders, and nearly everyone in this population group had prior contact with criminal justice or public health.  The data allowed the authors to construct a predictor of future gun homicides based primarily on social networks, a methodology that is now going to be used by the police to identify and visit with these high-risk kids and adults.  As Papachristos puts it, “It’s who you hang out with that gets you into trouble.”

Papachristos and Wildeman are planning to extend their research to cover the entire city of Chicago, and perhaps the Chicago PD will be able to mount a citywide program to monitor the social networks that breed the violent use of guns.  But the idea that guns are being used to commit violent crimes by people who know each other and band together is hardly new.  In fact, it’s not only humans who behave this way – the same type of behavior can be found in animals and even insects, and this has been known for nearly a hundred years.

Back in the 1920s a statistician named Alfred Lotka and a mathematician named Vito Volterra developed a statistical analysis (known as the Lotka-Volterra equations) that are used by ecologists to predict how different species occupy and protect their home territories.  This equation was then picked by a UCLA anthropologist, Jeffrey Brantingham, to study the territoriality of street gangs in Los Angeles and the links between each gangs’ territorial imperatives and gun violence.  What Brantingham found was that the further away from the gang’s headquarters, the less gun violence was committed by members of each gang.  The closer to the gang headquarters, the more shootings took place.  The behavior of the gangs was no different from the behavior of hyenas or bees. Want to avoid being attacked? Stay away from the place where the guys with the guns are found.

The research just published by Papachristos and Wildeman defines gun violence territory not from a geographic, but from a social network perspective.  It’s not about which street you walk on, it’s who you hang out with that predicts whether you’ll get shot or use a gun to shoot someone else. But when all is said and done, aren’t the findings by Papachristos and Wildeman on the one hand, and Brantigham on the other, really two sides of the coin?  After all, people tend to spend their time with people they know.  Call them a ‘group,’ a ‘gang’ or whatever, the tendency of humans to associate with one another in an organized manner is as old as humanity itself. It also seems to be as old as the existence of all living species.  Maybe the cops should spend a little less time giving out parking tickets and spend a little more time at the zoo.