Accidents Don't Happen

Arthur Kellermann addresses gun violence and injuries as preventable public health problems

By John D. Thomas

It was five days before Christmas in 1993 when two young Atlanta brothers found an interesting toy in their mother's bedroom--a .25-caliber semiautomatic pistol. According to a news report that appeared the following day in the Atlanta Constitution, "Although the youngsters removed a magazine of bullets from [the gun], one bullet remained in the chamber, which the boys didn't see. . . . Apparently thinking the gun was empty, a twelve-year-old boy pointed it at his younger brother's head and pulled the trigger." The injury was fatal.

While many might consider that death a tragic accident, Arthur Kellermann says it simply didn't have to happen. He says the gun should have had "a mechanically simple magazine safety, so when a ten-year-old gets ahold of a semiautomatic pistol and pulls the magazine of bullets out and starts pointing it at his friends thinking it's unloaded, the round left in the chamber can't be discharged because you cannot pull the trigger when the magazine is out of the pistol. To my mind, it's unconscionable that isn't a required design feature of every pistol manufactured or sold in the United States."

As director of the Center for Injury Control (CIC) in the Rollins School of Public Health, Kellermann approaches injuries not as random, unavoidable acts but as preventable public health priorities. "Injury is a gigantic public health problem, although it is not conventionally thought of the way we think of cancer or heart disease or infectious diseases," he says, sitting in his sunny, cluttered office on Clifton Road. "It's the leading cause of death in the United States for Americans between the ages of one and forty-five. . . .

"You may be in great shape," Kellermann says, "a nonsmoker, and eat the right foods. But before five o'clock tonight [you or I could] be dead or permanently disabled from an event the public considers an `accident.' However, there's really no such thing as an accident. Injuries affect high-risk groups and follow an often predictable chain of events--as surely as lung cancer and heart disease follow smoking. Public health has taught us that any adverse health event that is predictable is also preventable. It's that simple."

A 1980 graduate of the Emory School of Medicine who also holds a master's degree in public health from the University of Washington and an undergraduate degree in biology from Rhodes College, Kellermann returned to Emory in October 1993 to start the CIC. Prior to that, he was chief of emergency medicine at the University of Tennessee, Memphis; medical director of the emergency department at Memphis' county hospital; and medical director to the Memphis Fire Department and Emergency Medical Services Bureau.

Kellermann, who began studying gun-related violence as a Robert Wood Johnson Clinical Scholar at the University of Washington, accepted the CIC position to focus on big-picture issues. "It became increasingly apparent to me that no matter how well we ran the emergency department, no matter how well we taught residents, until we address fundamental social and medical issues that are affecting our society and learn how we can better prevent injuries and other major health problems . . . we're not going to get a handle on this problem."

The idea of promoting research centers devoted to investigating the prevention, treatment, and rehabilitation of injuries originated in the mid-1980s at the Centers for Disease Control and Prevention. Currently, Emory's CIC is one of a handful of such programs around the nation. While other centers are known for their work on pediatric injuries, rehabilitation, or injuries related to automobile accidents, Kellermann says the CIC's major strength is in the area of violence prevention.

It was the death of Motown recording star Marvin Gaye that provided the initial spark for Kellermann's research. "I was sitting in the student center [at the University of Washington] when the radio news show reported that Marvin Gaye had been shot by his father . . . ," Kellermann recollects. "I looked at my friend across the table and said, `This is nuts. There are all these guns in houses, a lot of them are kept for protection, and yet it seems like every other day you hear about somebody shooting their wife, or a son gets shot by his father. Surely somebody has looked at a gun in the home as a risk factor or a protection factor for violent death.' "

Actually, Kellermann found an almost absolute void in the consideration of that question. The most relevant item he discovered in the medical literature was a one-line mention in an old issue of the New England Journal of Medicine that asserted that a gun in the home was six times more likely to be involved in an accidental death of a family member than to be used to kill an intruder in self-defense. "I saw that observation quoted repeatedly in subsequent editorials or medical reviews but no additional research on the question," he says.

Kellermann has spent much of his professional life trying to fill that gap. His studies have found a strong link between guns and violent death. For example:

Even though Kellermann counsels against keeping guns in the home, he is not an anti-gun zealot. "I grew up around guns," he says. "My dad taught me how to shoot when I was eleven or twelve years old. Firearms are fascinating pieces of equipment. I enjoy the sport of shooting, although I rarely shoot anymore. However, as a clinician, as someone who is committed to emergency medicine, it is equally evident to me that firearm violence is wreaking havoc on public health."

With his latest project, Kellermann hopes to alter that trend by moving from merely pointing out problems related to gun violence to actually effecting a solution. "What I have done up to this point has been primarily to identify, characterize, and hopefully make available to the public, information about [handgun] risk," he says. "It's time to move on, to try various approaches to preventing firearm violence. Some will work and some won't. Evaluation research is needed to tell the difference. But program evaluation is often regarded with great distrust by those who consider it an arbitrary and often unfair judge that simply says, Thumbs up or thumbs down, the program worked, the program failed. We now know, particularly in issues as complex and challenging as violence, that evaluation has to be a fluid and evolving process. It should provide a feedback loop that permits a program to evolve and be refined over time."

Recently, the CIC received a $500,000 grant from the National Institute of Justice, the Centers for Disease Control and Prevention, and the Office of Juvenile Justice and Deliquency Prevention to examine the problem of youths and firearms in Atlanta. The grant was the first of its kind awarded by the U.S. Department of Justice to public health researchers. With that funding, Kellermann will be joining forces with numerous organizations in the metropolitan Atlanta area who were brought together through the federally sponsored Project PACT (Pulling America's Communities Together).

Kellermann says the focus of the study, called "Youth, Firearms and Violence in Atlanta: A Problem-Solving Approach," came out of a group effort. "All the key groups--from the faith community to youth to housing to the judiciary to law enforcement to public health--convened across jurisdictional lines to identify problems and assign priorities to those problems," he says. "And out of that process youth and deadly weapons emerged as a key priority for every single one of those groups. . . . It's a huge problem."

As an indicator of just how bad that problem is, the Centers for Disease Control and Prevention recently reported that of all the teenagers killed in America in 1991, 88 percent died from a gunshot wound. And a recent Louis Harris poll of schoolchildren found that one-third believe their life will probably be ended prematurely due to gun violence.

According to Kellermann, many programs calculate their successes on the amount of work that has been done, not by how the problem was affected. "In the case of violence research, it isn't enough to say, We arrested so many suspects, we bought back so many guns, we put up so many billboards, or we ran so many public service announcements," he explains. "The bottom line is, is our community more violent or less violent? Are more kids getting killed or are fewer kids getting killed? That's the kind of information we're committed to finding out."

To do this, Kellermann and others from the CIC will be examining changes in the rates of handgun-related crimes among Atlanta youth and then feeding that information back to the organizations participating in the program. Kellermann says the numbers he will be gathering and disseminating will enable groups to see if their strategies are working. For example, are gun buy-back programs in a certain area decreasing the rate of violent crimes there, or are educational programs focusing on safe handgun storage in the home making a difference? If law enforcement takes a more proactive approach to gun-carrying by youth, what impact will that have?

The CIC's role will be to help find out what does and does not work. "The strategies that are adopted by community groups, the law enforcement community, and juvenile justice two or three years from now may be very different than what we're doing today because we will have learned in the process that certain tactics are quite effective and other tactics don't work," Kellermann says. "And rather than continuing to pour volunteer effort, time, resources, and money into a set of strategies with mixed results, we will hopefully, God willing, be able to redirect resources to those strategies that look like they are paying off. If we find that none of it works, then we pull the plug on the whole thing, go back to square one, and start over. If we find out that a lot of bright ideas don't work, we'll be disappointed. However, we'll know more about the problem than when we started. Any way you look at it, that's progress."

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