An expert in medicine and public health, ranging from infectious diseases, to injuries, and mental health, Dr. Mark Rosenberg served 20 years with the Centers for Disease Control and Prevention (CDC), including early work in smallpox eradication, enteric diseases, and HIV/AIDS. He was instrumental in establishing CDC’s National Center for Injury Prevention and Control and became the first permanent director in 1994, serving as director and Assistant Surgeon General until 1999. He has worked with President Oscar Arias of Costa Rica to organize a coalition to address road traffic injuries throughout Latin America and the Caribbean. He is the CEO of the The Task Force for Global Health.
Here is a transcript from his lecture at UW May 5, 2014:
For several reasons it is a special honor and pleasure to be able to speak to you here today. First, I am delighted to be speaking to the Washington Global Health Alliance because you are a model for what we hope to do in Atlanta, pulling together the Atlanta Global Health community to make a whole that is larger than its parts, get a little closer to global health equity together than we might do alone. Second, one of your distinguished residents, Chris Murray, has observed that “Injuries, which account for 10% of global mortality, are often ignored as a major cause of death.” So it is nice to be able to put violence on a global health agenda that is usually dominated by a focus on diseases. And finally, because we are in the Foege Auditorium. Bill Foege was my teacher when I was a preventive medicine resident at CDC in 1975. He later became my boss, then my mentor, and then a very special friend. The wonderful American author Philip Roth, writing a eulogy for his mentor who died at the age of 103 told how his relationship with his mentor had developed. “To cut to the chase,” he wrote, “Bob and I fell in love.” That is the ultimate payoff of having a wonderful mentor. I have been so lucky and that’s why I am so moved to be speaking here in the Foege auditorium.
I want to talk to you about violence prevention, with a special focus on gun violence. And I want to make three points.
1. The prevention of violence must be based on science. Science is every bit as important here as it is in the development of pharmaceuticals and new medical devices, and it will be every bit as effective as it has been in the fight against heart disease, cancer, and road traffic injuries. We have every reason to be optimistic about the ability of scientific research to deliver us to safety.
2. But keeping science in the forefront won’t be a slam dunk because there are challenges— including political forces and strongly held social and cultural beliefs—that may stand in our way. We need to keep politics from stopping or interfering with our research. Public health is inherently political, and the issue of firearm injuries is more contentious than many public health fields and therefore subject to more political intrusions. But we must support our scientists so that they can collect and examine the evidence and then reach decisions based on it. We cannot afford to let scientific research be contaminated, manipulated, or stopped by organizations or individuals driven by their own economic gain or their own personal agendas. We need to be wary of arguments driven by ideology rather than evidence.
3. The field of violence prevention must be collaborative to succeed. Collaboration in the service of violence prevention is not just the nice, polite, or politically correct thing to do, but it is a matter of life and death. And it is hard work that does not come naturally.
Vi Harwell: An Example of Science in Real Life
I want to share with you a very personal story about someone else who taught me a tremendous amount, someone who was steadfast in her pursuit of the truth.
I first met Vi Harwell, when she was in an intensive care unit and not talking or interacting with her caretakers or the people around her. I had trained as a psychiatrist so her doctors thought I would be able to get her to communicate. I introduced myself and sat with her, and sat and sat and sat. And then came back and sat. And finally she started to open up.
Vi Harwell grew up in a family and in a place where violence was common. When she was a child, her brother, Bobby, had intervened in an argument that a young, intoxicated man was having with a woman. The young man thought Vi’s brother had embarrassed him and disrespected him and several days later he sought revenge by shooting and killing Vi’s brother.
Vi went on to marry Alex, the first black State trooper in Tennessee And Vi herself became the first black woman elected to the school board in Pulaski, TN. She even had her own radio show. They had an 8-year-old son, little Alex.
But her husband felt that Vi was neglecting him, that she was too busy with her work. She was becoming better known than he was. For him, this was unacceptable because it wasn’t consistent with the image he thought the man of the household should have. The tension grew between them, and Alex started to drink more and threaten her more. Things got so bad that Vi finally asked her husband to move out of the house. Her husband was furious and drank even more. He waited one night for Vi’s friend to leave their house, and then went up behind Vi, put his 357 magnum to the base of her skull and fired the gun at point blank range.
Vi survived, but she was totally paralyzed from the neck down, dependent on a ventilator. She could swallow and she could speak, but only if she timed it with the exhalation of the ventilator.
That’s when I met Vi at the Shepherd Center in Atlanta. Over a period of 4 years, we got to know each other very well, talking by phone almost every week. She was one of the most amazing people I have ever met. Vi lived in fear that her respirator might become disconnected and that she would be powerless to call anyone or do anything.
And one night, in March 1994, that happened.
Vi had started going out with her husband in about 1983, and if only we knew then—and applied--what we know now about violence prevention things might have been so very different.
In Vi’s community young black men were killing other young black men so frequently that there was a sense that violence was inevitable, senseless, and not preventable. Young black men like Vi’s brother Bobby were dying in large number.
When we compiled the homicide rates for the U.S. and compared them to rates for other comparably developed countries, the U.S. stood out.
When we compared the rates for young black men in the U.S. –third line from top--with the rates from other countries, we saw that the rates went on and on…
But we have learned that violence is preventable. Criminal justice, in large part, had focused on intervention after the fact, using both specific deterrence and incarceration. Public health does not just try to rescue drowning swimmers from the river, but it goes upstream “to see who is throwing them into the river.”
Using Science to Prevent Violence
We have developed a scientific framework that helps us understand homicides—based on science: What’s the problem? What are the causes? What works?
How do you do it, how do you implement the programs and policies that work?
The same questions can be asked about what happened to Vi, intimate partner violence or gender-based violence: What’s the problem? What are the causes?
What works? How do you do it?
The impact on Vi’s son, little Alex, was great and very long lasting. He used to wake up with nightmares.
LeNita, Vi’s sister explained, “Alex, Vi’s son, had some bad dreams and woke and came to my bedroom. He had a nightmare saying that his dad was chasing him with a butcher knife. We calmed him down and assured him that he loved him. We told him that his mom loved him too, and that he didn’t ever have to worry about his dad chasing him with a butcher knife because his dad loves him. I just let him get in bed with us, and he went to sleep.
“Little Alex had been a wonderful student before he moved here to Chicago with us. But during the winter he started having a lot of problems. His teachers let us know that he was not doing his schoolwork or turning in his homework. And worse than that, he was lying about it. When we found out, I started going with him to a child therapist. That worked great. It really turned him around and he went from being a real problem to where he was selected as the star student of the week. They invited me to come to his class on the day he was supposed to get the award. It was a surprise. I was delighted and he was surprised and very happy.
After he got the award, he introduced me to his class. He said, 'This is my mother, LeNita.'” Better, yes; healed, no. He got better for a while, but had a very hard time focusing his life, completing school.
Research Has Taught Us A lot
We used to think that the cost of violence was primarily the sum of the costs of taking care of the acute injuries that resulted from that violence. But we have had to make a huge paradigm shift because of what the science has shown us.
There are several notable findings:
The game-changing studies on adverse childhood events by Felitti and Anda and many others demonstrated empirical associations between early exposure to violence and subsequent major causes of mortality in adulthood, such as the non-communicable diseases or NCDs. Early exposure to violence, neglect, and abuse leads to children who grow up hyper-vigilant, and unable to calm themselves or tamp down strong hormone- driven feelings to fight or take flight. As they grow up and across their life span they are at higher risk for hypertension, heart disease, asthma, substance abuse, high risk sexual activity and sexually transmitted diseases, suicide, and violence.
And now we are starting to understand the biological underpinnings for these associations. Traumatic stress such as that associated with violence impairs brain architecture (both structure and function), and can confer lasting damage at the most basic levels of the nervous, endocrine, and immune systems. These exposures can even influence genetic alteration of DNA (Danese and McEwen 2009; Anda and others 2010). Nurture affects nature.
Violence extends across the whole life-span from child abuse and neglect to elder abuse, including suicide and self-directed violence. And each type of violence can be understood with the same scientific approach, asking the same 4 questions.
Keeping Politics Out of Research
The second big point I want to make is that we need to keep politics out of our research, and make sure that our science is driven by evidence and not ideology. Because politics interfered with research at CDC, we don’t understand what we need to know about how to prevent firearm injuries. Those we are trying to serve are paying the price, with lives lost, families shattered, and children and communities terrorized.
In 1983, the same year that Vi’s son Alex was born, Bill Foege convinced me to come back to Atlanta and my family moved down from Boston. I returned to the Centers for Disease Control (CDC) to help start a program looking at violence as a public health problem. We started to put together a science base for the prevention of firearm injuries. In the 1990s, the National Rifle Association and the forces of politics killed that program.
Since the Newtown massacre, the national statistics on gun violence have been widely reported. Firearms deaths number more than 30,000 each year, and ⅔ of these deaths are suicides. Tens of thousands more people are seriously injured by guns. Those injuries impose significant and frequently life-long burdens for care and rehabilitation on families, communities and the health care system. But we have known little about these deaths other than how many occur each year.
We faced a similar challenge 50 years ago when we realized that cars were killing too many of our citizens. In the mid-1960’s the federal government invested hundreds of millions of dollars in research that helped us reduce risks related to motor vehicle crashes. We discovered ways to make cars safer by adding front and side impact protection, seat belts, air bags, anti-lock brakes, and elevated rear stop lights. We learned how to improve roadway design to make roads safer, and we understood how to make drivers safer by passing stricter laws that could get the majority of drunk and impaired drivers off the road. As a result of this research, we saved more than 325,000 lives between 1960 and 2002.
At the National Center for Injury Prevention, we set out to do similar research on firearm injuries, a problem that accounted for about the same number of deaths as motor vehicle crashes. We wanted to answer the same four questions that we use to understand other specific forms of violence.
What is the problem? We wanted to know how many firearm-related injuries occur; where, when and how they occur; the characteristics of the shooters and victims and the relationship between them; and the circumstances of death and the weapons used.
What are the causes? What are the factors that increase or reduce risk? We found, for example, that the presence of a firearm in the home, rather than being protective, is associated with a 300% increased risk of homicide and a 500% greater risk of suicide.
What works? What practices or policies prevent firearms deaths and injuries? Some simple interventions have proven effective (childproof locks, storing firearms locked and unloaded), but we have not yet adequately studied the impact of most public policies such as gun-owner licensing, firearm registration, background checks for criminal histories or mental illness, or barring access to certain types of weapons or ammunition. We don’t know, for example, how death and injury rates are affected by prohibiting gun ownership by felons or the adjudicated seriously mentally ill. We just don’t have the evidence.
How do you do it? How do you implement effective practices and take them to scale? This is similar to the challenge of disseminating best practices in medicine: we would like to generate and deliver evidence-based practices that could be widely adopted.
In the area of “firearm injuries”, we know a fair amount about the first two steps, but woefully little about “what works” and “how do you implement and scale up the things that work.”
So, at CDC we set out to answer these questions by collecting surveillance data on firearm injuries and supporting investigator-initiated peer- reviewed research. Had we done so then, we might have saved many of the more than half-million lives lost to firearms injuries in the last 17 years.
But the NRA leadership stopped us by misrepresenting our research. They told their members that our research would result in all firearms being confiscated. And the pro-gun constituents launched relentless attacks on our science, calling the injury center the “cesspool of junk science.” Six senators wrote to the secretary of HHS requesting that I should be fired and the injury center shut down.
In 1996, they persuaded a number of congressmen and senators to eliminate firearm injury research at CDC. Led by Congressman Jay Dickey, a republican from Arkansas, the House removed $2.6 million from the CDC budget, an amount designated to support a firearm injury surveillance system. Although the Senate restored the money to the budget for other purposes, Congress added language to CDC’s appropriations bill that said no funds could be used “to advocate or promote gun control.”
We were in the business of research, not advocacy, but this ambiguous language was a threatening shot across the bow that effectively undermined firearms research. Federal bureaucrats grew wary of conducting research about which the NRA could harass them mercilessly. David Satcher, then director of CDC, asked for a review of CDC’s firearm research by a panel of highly respected scientists and this review concluded that the research was extremely well-done, important and that there should be more of it.
But it wasn’t only the NRA and their allies that undermined our effort.
Even scientists we had funded turned against us. I don’t think it would come as a surprise to hear that scientific research is an intensely competitive enterprise. Nor should it come as a surprise that a research area that has many committed scientists competing for very limited resources, tends to have its share of disgruntled scientists and opportunistic administrators who are not only willing to sacrifice a field like gun violence research but will actively participate in the attack when it suits their own personal self-interest. They turned on scientists who were and still are seeking truth based in science. We desperately need more leaders like David Satcher who not only allow scientists to pursue questions when the questions and answers they generate may not be politically popular but they will actively defend them when they come under attack.
The money that CDC spent on firearm injury research fell drastically, by more than 95%. And at CDC today, there remains a small group of extraordinarily dedicated and able researchers, but “guns” is a four letter word that makes researchers cringe because it’s a red-flag that makes it very difficult to get a paper cleared or research approved.
Beyond the U.S.
We still face significant challenges in bringing the benefits of violence prevention to low- and middle-income countries, where men, women, and children bear 90% of the global burden of violence, an enormous burden that hits the world’s poorest people in the world’s poorest places and helps to perpetuate extreme poverty. The biggest obstacle is that we lack proof of effectiveness for many interventions in low- and middle-income countries and without the proof of effectiveness neither country governments nor donors want to invest in preventive interventions. Without their wanting to invest, we can't demonstrate effectiveness. In addition, most low- and middle-income countries don’t have the capacity to collect the data needed to measure cost-effectiveness, and rigorously evaluate the outcomes.
Collaboration in Violence Prevention
My third and last major point is that if we are to be successful going forward, we will have to do a better job of respecting, understanding, and working with each other. In the area of firearm injuries, collaboration has a very special meaning: our research must simultaneously meet two objectives. The first is to reduce firearm deaths and injuries; the second is to be mindful of the legitimate concerns of responsible, law-abiding gun-owners.
This task is similar to finding a cancer chemotherapy that will both stop tumor growth and preserve that patient’s overall wellbeing. There are plenty of drugs that will stop tumors and shrink them away. If this were our only concern, we would not need research to find new drugs. The problem is that these drugs are toxic and, while stopping the tumor, they also severely damage the kidneys, liver, and heart. If we were not concerned with the tumor’s growth and concerned only with protecting the patient’s kidneys, liver, or heart, we might not need research to find new treatments. When we want to both stop the cancer and preserve the patient’s vital organs, the challenge is much greater and we need good scientific research to find the solutions.
So it is with preventing firearm injuries and protecting gun rights. Ignoring either objective might make research unnecessary. We could disregard the risks of death and injury, and — as the NRA suggests — do nothing to limit access to firearms, the types, number, or way they are sold. Or, we could set aside gun rights and prohibit civilian ownership of firearms. Either of those paths makes easy work for the policy makers.
But, the constitution — and our duty to protect the lives of family and community members — require us to pursue both objectives and make informed choices. We need research to find out what works to reach both objectives, to find the best way forward.
Collaboration, especially across types of violence, across sectors, and across stakeholders among whom there is so much distrust—is challenging to be sure. Even when the science is easy, people are hard, and institutions are impossible. There is competition for credit, power, and funding. Obstacles (and opportunities) occur every day at every level: global, multinational agencies, regions, countries, communities. Stakeholders speak different languages, have different cultures and every organization wants things its own way.
Collaboration, like democracy, is not perfect, but it offers a better chance than any other option we have.
Vi Harwell lived the last four years of her life as a quadriplegic and ultimately lost her life because of a firearm injury. That was almost 20 years ago, and between then and now more than 600,000 people lost their lives to firearm injuries in this country alone. This does not have to continue. Science has dismantled the superstitions of ignorance, one after the other. During our own lifetimes we have seen extraordinary progress made in protecting us from cancer, heart disease, mental illness, and death on the highway. So too, science will dismantle peoples' belief that violence is an inevitable part of being a human being.
We can’t let the science in a vital life and death area like this one, get side-tracked or derailed. But while it is just what we need for stayin’ alive, it won’t be easy. When Vi’s husband went on trial for shooting Vi, the jury was not allowed to hear the truth. They were not allowed to hear about domestic violence. Truth was remarkable for its absence. Vi’s husband testified that he had his 357 Magnum out for target practice even though it was pitch black outside; and he said that the gun went off “accidently” while he was standing in front of Vi. The medical examiner testified that Vi was shot at point blank range from behind her, and that a 357 Magnum required too much pressure on the trigger to go off accidently. In a gross miscarriage of justice, her husband was acquitted. We can’t allow a gross miscarriage of science. There is too much riding on this.
Jay Dickey, my arch-enemy when David Satcher and I testified before the House appropriations committee in 1966, was so angry that my CDC handlers had told me “Don’t you ever speak with him. It will be like throwing a match on gasoline. But one day his staffer called me to his office to see if I could explain some things to him. I did go and we spoke and as I was leaving he said, “The Congressman is here and would like to say hello to you.” What was I to do? I didn’t want to be fired but I didn’t want to be completely impolite so I went in.
Jay is a born-again Christian, Southern conservative Republican working for the NRA. And I was a young, Jewish liberal from the northeast. But over time we became good friends and came to know and trust each other. That trust is critical. We have come to agree that we must do more research to learn how to prevent firearm violence.
Writing about the situation in Egypt in the New Yorker last year, George Parker said something that could equally well apply to the stalemate between the sides that oppose each other on the gun issue:
“The core political problem …is … a culture of suspicion and confrontation, a mentality of winner-take-all…we have two groups that regard one another as obstacles to power, not as legitimate players in a complex game that requires inclusion and consensus.”
The prize—safety for our children, our families, our communities, and our country—and beyond—is too big a prize for us to lose. In the short-, medium-, and long-run, the cost of proceeding with our eyes closed to the truth will be much more than we as a civilized and caring society can afford.
I am deeply indebted to work done by so many advocates and researchers, bureaucrats and leaders, friends and mentors who have helped to totally transform this field and helped me understand so much more than I did when I first started working on violence prevention 30 years ago. In particular, for help with this presentation I want to thank Don Berwick, Alex Butchart, Jay Dickey, Bill Foege, Fran Henry, Howard Hiatt, Jim Mercy, and Jill Rosenberg.