In 1925, in the classic novel An American Tragedy, Theodore Dreiser portrayed a poignant yet powerful picture of youthful loneliness in industrial society and of the American mirage that beckons some of the young to disaster.
In 2012, an American tragedy of far greater urgency and public health importance is the alarming rate of homicide among young black men. Interracial homicide, whether the victim or the perpetrator is black, is abhorrent. Nonetheless, from the perspective of the health of the general public, the circumstances in which a young black man is both the victim and the perpetrator cause far more premature deaths.
Homicide is, far and away, the leading cause of death of young black men. In stark contrast, accidents are, far and away, the leading cause of death among young nonblack men and women of all races and ethnicities. Black men are 6 times more likely to die as the result of and 7 times more likely to commit murder than their white counterparts. One eighth of the population is black, but one half of all homicide victims are black. Their reduced life expectancy of more than 6 years would be improved more from eliminating homicide than abolishing any other causes of death except cardiovascular disease or cancer.
Influence of homicide on racial disparity in life expectancy–United States, 1998.
From 1999 to 2009, among those aged 15 to 34 years, there were 106,271 homicides, 85% (89,887) among men and 49% (52,265) among black men. One major and hotly debated issue is firearms. Specifically, 81% (85,643) of all homicides were due to firearms, including 91% (47,513) among black men.
Centers for Disease Control and Prevention, National Center for Health Statistics
Compressed Mortality File 1999-2009 CDC WONDER Online Database, compiled from Compressed Mortality File 1999-2009 Series 20 No. 2O, 2012.
All attempts to address this complex issue should include, but not be limited to, optimizing the health of the general public, the strength of the existing evidence, and the constitutional right of individuals to bear arms.
In most circumstances, public health practitioners are charged to identify threats to the health of the community and to bring scientific evidence to the attention of policy makers, even if the threats are lawful and whether or not policy makers choose to act on that evidence. For example, cigarettes are both lawful and popular, but public health support of laws controlling their exposure to the general population has contributed to the reduction of the premature mortality they cause.
To date, however, this has not been the case for firearms. For policy makers proposing new gun laws, establishing an evidence-based legislative record may be especially important.
- Vernick J.S.
- Rutkow L.
- Webster D.W.
- Teret S.P.
Changing the constitutional landscape for firearms: the US Supreme Court's recent Second Amendment decisions.
Nonetheless, federal public health practitioners are barred from such activities, due, in part, to the Anti-Lobbying Act and a 1996 action by the Congress of the United States, which defines such activities as “lobbying,” which is considered a felony. Instead, federally employed public health officials are instructed by legislators to consider only the existing totality of available evidence. To date, this primarily includes descriptive data that are useful to formulate but not test hypotheses.
Statistical association and causation: contributions of different types of evidence.
Nobody would disagree that individual behavior change is an important and necessary strategy for lowering homicide rates, but there is legitimate debate about whether it would be sufficient. It seems plausible, if not likely, that major societal changes amenable to responsible government but beyond individual control also are needed to achieve decreases in premature mortality from homicide among young black men.
At present, we are aware of no reliable evidence on these important questions from analytic studies designed a priori to test hypotheses. For example, there is no reliable evidence about whether mandatory prison sentences for possession of an unlicensed firearm would have a positive, negative, or no impact. There is an urgent need for a sufficient totality of evidence on which to base the most rational judgments for individuals, as well as policy decisions for the health of the general public. Although it is not incumbent on policy makers to follow recommendations, if reliable evidence supports the current legislative position, then there would be a rational basis on which it should be upheld. It also may be that reliable evidence emerges to support modifications in laws concerning exposure to firearms. Outcomes may range, in theory, from relaxing current guidelines, to enforcing the status quo on firearms, to greater licensing requirements or some other solution. Any of these outcomes would be only one component of a multifactorial and multidisciplinary strategy to combat the epidemic of premature mortality from homicide among young black men. Death is inevitable, but premature death is not, including among young black men.
- Levine R.S.
- Rust G.
- Kilbourne B.
- et al.
United States counties with low black male mortality rates.
An urgent and necessary first step to abort this epidemic should include increased awareness of the general public, health care providers, and public health professional organizations. One example of a successful strategy is the US National High Blood Pressure Education Program.
National Heart, Lung, and Blood Institute
Guidelines in Development: The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8).
Before this program, hypertension had been established as a leading cause of premature morbidity and mortality from stroke and coronary heart disease. Nonetheless, only one half of hypertensive subjects were being detected; of these subjects, only one half were treated and hypertension was controlled in only one half. Thus, only one eighth of people with hypertension were effectively treated, a figure that has increased to more than one half in the last 41 years. This is due, in part, to the increased awareness of healthcare providers and the general public about a sufficient totality of evidence on the individual risks and benefits of therapeutic lifestyle changes and the need for multiple drug therapies of life-saving benefit. The 8th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure is being drafted by the US National Heart, Lung, and Blood Institute. Every decision reached by the best possible independent medical review is subject to modification by other academic and public health experts, including various governmental agencies. The National Heart, Lung, and Blood Institute clearly states that their “sponsored clinical guidelines are developed by voluntary expert panels which they convene and are, therefore, not official government positions.” Nonetheless, they may inform policy decisions of other government agencies and other groups.
Medical and public health practitioners should be free to gather a sufficient totality of evidence and make official recommendations. To paraphrase Martin Luther King, Jr, the renowned black clergyman, activist, and prominent civil rights leader who preached and practiced nonviolence but was murdered by a gun—substandard science anywhere is a threat to science everywhere.
Influence of homicide on racial disparity in life expectancy–United States, 1998.MMWR Morb Mortal Wkly Rep. 2001; 50: 780-782
- Centers for Disease Control and Prevention, National Center for Health Statistics
Compressed Mortality File 1999-2009. ()
- Vernick J.S.
- Rutkow L.
- Webster D.W.
- Teret S.P.
Changing the constitutional landscape for firearms: the US Supreme Court's recent Second Amendment decisions.Am J Public Health. 2011; 101: 2021-2026
Statistical association and causation: contributions of different types of evidence.JAMA. 2011; 305: 1134-1135
- Levine R.S.
- Rust G.
- Kilbourne B.
- et al.
United States counties with low black male mortality rates.Am J Med. 2013; 126: 76-80
- National Heart, Lung, and Blood Institute
Guidelines in Development: The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8). ()
Published online: January 17, 2013
Conflict of Interest: Dr Hennekens was funded for 5 years as principal investigator on 2 investigator-initiated research grants funded to Florida Atlantic University by Bayer ; serves as an independent scientist in an advisory role to investigators and sponsors as Chair or Member of independent Data and Safety Monitoring Boards for Actelion, Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Canadian Institutes of Health Research, and Sunovion; to the US Food and Drug Administration, US National Institutes of Health, and UpToDate; and to legal counsel for GlaxoSmithKline and Stryker; serves as a speaker for the Association of Research in Vision and Ophthalmology, the National Association for Continuing Education, PriMed, and the International Atherosclerosis Society; receives royalties for authorship or editorship of 3 textbooks and as co-inventor on patents for inflammatory markers and cardiovascular disease that are held by Brigham and Women's Hospital; and has an investment management relationship with the West-Bacon Group within SunTrust Investment Services, which has discretionary investment authority and excludes investments in pharmaceutical or device companies. Drs Drowos and Levine have no disclosures.
Authorship: All authors had access to the data and played a role in writing this manuscript.
© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.