www.mdmazz.com - The Art of Healing Blog - January 6th 2013




Sandy Hook and empty shoes


The tragedy at Sandy Hook brings back memories of a previous push for gun safety and crime reduction some twenty years ago which I would like to share with you. I wrote a letter to the Bergen County Medical Society in 1994 regarding the Long Island Railroad massacre where one of my young patients, Amy, lost her life. In addition to my sadness, I discussed the issues of violence and the role of physicians in mitigating such violence. The letter also discussed the courage and faith of her family in the face of such tragedy. I also called on members of the society to join in a silent March on Washington to be held on September 20, 1994. A sea of 38,000 empty shoes, representing the number of Americans dying yearly from gun violence would surround the reflecting pool of the Lincoln Memorial. As it explained in the letter violent crime had been increasing from 1960 to 1992 by 371 percent. Almost two million violent crimes were occurring yearly or 1 every 22 seconds. I stated that: " Physicians and the nation should call for a 90% reduction in violent crime by the year 2014." I also suggested the incorporation into the medical school curriculum a course on violence aimed at methods for physicians to recognize and help patients deal with conflict in non-violent ways. Nearly twenty years later, in some respects, we have made progress. Overall violent crime has been in an almost continual decline for the last 20 years. It was 758.2 per 100,000 populations in 1991 and now the latest final figures from 2009 are 429.4 or approximately a 43% reduction. This is not the 90% reduction hoped for but a marked improvement. However it is still about double the 1960 rate of violent crime. The murder rate was 9.5 per 100,000 populations in 1991 and the figure from 2009 was nearly one-half at 5.0. This is approximately 400% higher than the average European country. The CDC estimated in 2005 the cost of gun violence. Combining the direct medical costs of treating fatal gun injuries with the economic damage of lost lives, firearms-related deaths cost the United States $37 billion per year. Of course, the emotional cost to families, friends and the nation's image can't be even comprehended no less computed. However the incidence of mass shootings have been on the rise from that time period culminating in this recent tragedy at Sandy Hook. Clearly different forces are at work here with the intersection of access to rapid-fire weapons, graphic violent media, severe mental illness and generally younger males. It is a sad state of affairs when a society can no longer provide safety for those who gather in schools, malls, movie theaters and churches. With regard to the physicians' role in reducing violence it is an even sadder situation than twenty years ago. Unlike for other major causes of death federal medical research agencies are forbidden by law to finance studies that aim to reduce the harm from guns or, as the law phrases it, "advocate or promote gun control." It is totally incredible that objective science cannot be carried out in a research area where over 30,000 American lives could be saved each year. The American Medical Association is fighting a law that Florida enacted last year forbidding doctors from questioning patients about their guns, which Dr. Jeremy Lazarus, the AMA president, says has had a "chilling effect" on physicians asking questions he believes are vitally important to patients' health and safety. "Physicians should not be restrained in any way from having a discussion with their patients about things they think are helpful for their health" he said. This kind of interference by government is usually associated with totalitarian states and as physicians, we must fight any law which causes us, by complying, to harm our patients. So what can we as a society of physicians do to aid in the battle to make America a safer place? a> The AMA and local societies should demand that physicians be encouraged not restricted from federal support to carry out research using real world statistics and to be able to point out potential solutions to the excessive levels of gun violence and mass shootings in this country. Local laws like the ones in Florida must continue to be fought and brought to a national level. b> The Bureau of Alcohol Tobacco Firearms and Explosives has been without a director for six years and the AMA should demand of Congress to allow someone to take the role. Also, under current laws the bureau is prohibited from creating a federal registry of gun transactions and needs to investigate each case by calling manufacturers and wholesalers each time. This wastes time and has nothing to do with second amendment rights. The AMA needs to demand that these restrictive laws be changed. c> An op-ed in the NY Times on December 25th , 2012 entitled "Our failed approach to Schizophrenia" points out that: "the swing in mental health care over the past 50 years: too little institutionalizing of teenagers and young adults (particularly men, generally more prone to violence) who have had a recent onset of schizophrenia; too little education about the public health impact of untreated mental illness; too few to talk about and treat severe mental disorders - even though the medications available in the past 15 to 20 years can be remarkably effective". And later he states: "Severely ill people like Mr. Lanza fall through the cracks, in part because school counselors are more familiar with anxiety and depression than with psychosis. Hospitalizations for acute onset of schizophrenia have been shortened to the point of absurdity. Insurance companies and families try to get patients out of hospitals as quickly as possible because of the prohibitively high cost of care". The AMA needs to encourage extended benefits for schizophrenics with clear rules for recommended commitment. Also it needs to encourage special programs to assist schools and educate physicians and counselors to better understand this serious ailment. d> The majority of Americans, since Sandy Hook, now believe that assault weapons have no place in the hands of ordinary Americans. The extreme minority opinion is fearful of gun confiscation and their need to be able to overthrow the government by force if necessary. Congress should pass the ban on assault weapons again; however, not in the weakened form that it was originally instituted. Quoting from the article in the December 19th issue of the NY Times entitled "Lessons in Politics and Fine Print in Assault Weapons Ban of '90s": "The federal ban also yielded mixed results in its decade of existence. A 2004 study by the University of Pennsylvania, financed by the Justice Department, found that the measure, which included a ban on ammunition magazines that could hold more than 10 rounds, had only a limited impact on gun crime. The study explained that part of the limitation in the law was related to all the exceptions to the law. Assault weapons and large-capacity magazines manufactured before 1994 were exempted from the ban, meaning that more than 1.5 million assault weapons remained in circulation. In addition, the country's stock of large-capacity magazines actually continued to grow after the ban, because it remained legal to import them as long as they had been made before the ban. " The AMA should take out national airtime to educate people about why the ban is necessary and how it in no way violates gun owners' legitimate rights under the second amendment. They also should insist on much improved background checks on all gun ownership to screen out those with mental illness or with a previous criminal record. New and stronger laws need to be implemented to deal with the lack of safely storing a gun or the buying of a gun for someone else, who would not pass the screening procedure. People violating these laws should be severely prosecuted. Unless a majority of Americans continue to understand the issues and believe in new legislation to prevent this type of violence no new laws will ever be passed. e> The AMA should further encourage primary care physicians to mention to patients that if patients have guns to make sure that they are kept under lock and key and said key inaccessible to other family members and visitors. f> Renewed efforts need to be made in large cities like Chicago to end the violence in the streets often affecting innocent youths. The AMA being located in Chicago could offer some new ideas such as hiring young people from the South and West Side, between the ages of 16 and 26, in a public works project to beautify the neighborhoods and to work with younger children in a summer type recreational programs. Two years ago, 30,470 people died from homicides or suicides using firearms, according to data compiled by the CDC. Gun-related fatalities are on pace to surpass deaths from automobile collisions by 2015. We owe it to the children of Sandy Hook to make progress on these issues as soon as possible and not have another 30,000+ empty shoes in 2013 and beyond. We owe it to my patient Amy as well. The success or failure of any and all new legislation will be clear in time but let us not let selfish interests and paranoia stop us from trying. To see the original 1994 letter and some of the responses from, for example, the now deceased Dr. James Todd who was then an AMA vice-president and former well-known Valley Hospital surgeon in Ridgewood, NJ see below. 1/6/2013
 [Also below see current updates to this blog as events unfold]
1994Letter1
1994Letter2
JimTodd
MikeAzzara

The following are some of the actions that have occurred since I sent my blog above as a letter to the AMA. A number of the Obama executive orders addressed some of the medical concerns in my blog directly.

President Barack Obama put into motion these actions by Executive Order as follows:

1. Issue a Presidential Memorandum to require federal agencies to make relevant data available to the federal background-check system.
2. Address unnecessary legal barriers, particularly relating to the Health Insurance Portability and Accountability Act, that may prevent states from making information available to the background-check system.
3. Improve incentives for states to share information with the background- check system.
4. Direct the attorney general to review categories of individuals prohibited from having a gun to make sure dangerous people are not slipping through the cracks.
5. Propose rulemaking to give law enforcement the ability to run a full background check on an individual before returning a seized gun.
6. Publish a letter from the Bureau of Alcohol, Tobacco and Firearms and Explosives (ATF) to federally licensed gun dealers providing guidance on how to run background checks for private sellers.
7. Launch a national safe and responsible gun ownership campaign.
8. Review safety standards for gun locks and gun safes (Consumer Product Safety Commission).
9. Issue a Presidential Memorandum to require federal law enforcement to trace guns recovered in criminal investigations.
10. Release a Department of Justice report analyzing information on lost and stolen guns and make it widely available to law enforcement.
11. Nominate an ATF director.
12. Provide law enforcement, first responders, and school officials with proper training for active shooter situations.
13. Maximize enforcement efforts to prevent gun violence and prosecute gun crime.
14. Issue a Presidential Memorandum directing the Centers for Disease Control to research the causes and prevention of gun violence.
15. Direct the attorney general to issue a report on the availability and most effective use of new gun-safety technologies and challenge the private sector to develop innovative technologies.
16. Clarify that the Affordable Care Act does not prohibit doctors asking their patients about guns in their homes.
17. Release a letter to healthcare providers clarifying that no federal law prohibits them from reporting threats of violence to law enforcement authorities.
18. Provide incentives for schools to hire school resource officers.
19. Develop model emergency-response plans for schools, houses of worship and institutions of higher education.
20. Release a letter to state health officials clarifying the scope of mental health services that Medicaid plans must cover.
21. Finalize regulations clarifying essential health benefits and parity requirements within Affordable Care Act exchanges.
22. Commit to finalizing mental-health parity regulations.
23. Launch a national dialogue led by Secretaries Sebelius and Duncan on mental health.

 NY SAFE Act: 13 signed by Gov. Cuomo

Further restrict assault weapons to define them by a single feature, such as a pistol grip. Current law requires two features.
Make the unsafe storage of assault weapons a misdemeanor.
Mandate a police registry of assault weapons.
Establish a state registry for all private sales, with a background check done through a licensed dealer for a fee, excluding sales to immediate relatives.
Require a therapist who believes a mental health patient made a credible threat to use a gun illegally to report the threat to a mental health director who would then have to report serious threats to the state Department of Criminal Justice Services. A patient's gun could be taken from him or her.
Ban the Internet sale of assault weapons.
Require stores that sell ammunition to register with the state, run background checks on buyers of bullets and keep an electronic database of bullet sales.
Restrict ammunition magazines to seven bullets, from the current national standard of 10. Current owners of higher-capacity magazines would have a year to sell them out of state. Someone caught with eight or more bullets in a magazine could face a misdemeanor charge.
Require that stolen guns be reported within 24 hours. Otherwise, the owner would face a possible misdemeanor.
Increase sentences for gun crimes including for taking a gun on school property.
Increase penalties for shooting first responders, called the "Webster provision." Two firefighters were killed when shot by a person who set a fire in the western New York town of Webster last month. The crime would be punishable by life in prison without parole.
Limit the state records law to protect handgun owners from being identified publicly. The provision would allow a handgun permit holder a means to maintain privacy under the Freedom of Information law.
Require pistol permit holders or those who will be registered as owners of assault rifles to be recertified at least every five years to make sure they are still legally able to own the guns.

Feinstein Senate Bill proposed:

Ms. Feinstein’s bill — which, unlike the 1994 assault weapons ban, would not expire after being enacted — would also ban certain characteristics of guns that make them more lethal. More than 900 models of guns would be exempt for hunting and sporting.
 

Rahm Emanuel’s attack at economic source of  resistance to gun regulation:

Fresh from persuading a $5 billion pension fund in Chicago to divest from companies that make firearms, the city’s mayor, Rahm Emanuel, on Thursday urged the chief executives of two major banks to stop financing companies “that profit from gun violence.”

NRA responses:

After a weeklong silence, the National Rifle Association announced Friday that it wants to arm security officers at every school in the country. It pointed the finger at violent video games, the news media and lax law enforcement — not guns — as culprits in the recent rash of mass shootings. Gov. Chris Christie of New Jersey, a Republican, said arming schools would not make them safer.
NRA concerns about second amendment rights.
LaPierre attacked the president's speech, specifically the part where Obama urged Americans not to "mistake absolutism for principle." That was an attack on gun owners who believe in an absolute right to bear arms based on the Second Amendment, LaPierre said, according to the New York Times. Highlights:
"I urge our president to use caution when attacking clearly defined absolutes in favor of his principles," LaPierre said. "When absolutes are abandoned for principles, the US Constitution becomes a blank slate for anyone’s graffiti."
Furthermore, there are only two reasons the government would want to expand background checks: In order to collect gun owners' names, and then "either to tax [guns], or to take them," LaPierre said. Obama wants to put "every private personal firearms transaction right under the thumb of the federal government," he added.
LaPierre also accused Obama of turning the word "absolutist" into "extremist," with a goal of getting law-abiding citizens to give up their guns "through scorn and ridicule."
If the president wins, LaPierre said, only criminals and rich people will be left owning guns. Ultimately, Obama thinks "the only principled way of making children safe" is making others less safe, LaPierre said.

Response to NRA 2nd Amendment claims:

The NRA never fought the original assault weapons ban in courts because while the 2nd amendment is currently interpreted to allow individuals to bear arms it never said that regulation of that right to provide safety to the people was not possible. Clearly the founding fathers did not intend to have criminals and the mentally ill carrying guns. So the 2nd amendment is not absolute.  If he were correct the courts would overrule the ban quickly. Then he goes on to say that there are only two reasons to expand background checks either to tax them or take them. This statement not only is obviously false because it is limited in choices but in the light of Sandy Hook it means that he is a demagog - a political leader who seeks support by appealing to popular passions and prejudices. The logical reason why a majority of Americans want this ban is to prevent the murder of our children, our parents, and our brothers and sisters. None of us give a damn about you or anyone else owning regular guns if they are safely distributed stored and used.  No one cares about the revenue from taxing guns. Taxes are not the way to regulate them.  The government knows where every car is for safety reasons and they have a right to know where every gun is. This info should be for law enforcement only. As to the need to overthrow a totalitarian government let us remember that the seeds of such a government, as with Hitler, are fueled with hatred and irrationality and demagoguery.   If such a government ever tried to establish itself here we would have the ability to overthrow such a takeover in this Internet age without one gun being fired. Just by taking down through the Internet any supporting companies their insanity would be stopped.  To think that we need to have states succeed again is just craziness. Once you are to that place then the second amendment won’t help you.  My father was a hunter and he loved going out with his friends or alone. He took care of his rifle and kept it safely away from us. If he were alive today he would realize that this is not about taking away his rifle. Especially if you live in a small town in the country you need a gun but you don’t have a right to have each new and more deadly technology. You can’t have rocket launchers or nuclear materials nor access to germ warfare.  Let us also not place money made from gun sales above human life. How effective these changes are remains to be seen and if the courts rule against them so be it but we owe it to the children of Sandy Hook to try.
 1/29/13




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