We have a public health crisis
It's guns.
In a letter to his colleagues across the country, pediatrician Joel Alpert urged action against “two epidemics that kill children.” One was tobacco products. The other was guns.
This was 1999. Alpert was president of the American Academy of Pediatrics, and he urged his fellow doctors to counter the powerful forces that fought against even reasonable control of either. “As advocates for children,” he wrote, “pediatricians must be proactive.”
Some members of the academy responded with letters lauding Alpert’s statement. Others excoriated him, calling his ideas “liberal foolishness” and saying guns save lives, stop crime and protect against tyranny, which is “the greatest threat to children,” as one letter writer put it.
Three months after Alpert’s letter was published, twelve students and a teacher were murdered at Columbine High School in Littleton, Colo., marking the start of a new era of school shootings and a horrific milestone in the story of guns in America.
When Alpert called firearm injuries an “epidemic” and aligned the campaign against them with one aimed at keeping cigarettes out of kids’ hands, he was naming guns as a public health crisis, in need of a public health response focused on the regulation of gun manufacturing and sales to reduce community-wide harm at its source, the literal barrel of the gun.
It was a radical position then. Today, firearms are the No. 1 killer of children and teens in the United States, more deadly than motor vehicles, more dangerous than the diseases pediatricians are trained to treat and prevent.
I was thinking about Alpert this spring after yet another mass shooting—Nashville, I think, but it could have been Louisville, Ky., or Allen, Texas, or Dadeville, Ala., or really any of the dozens of others in which children have been killed so far this year.
I had interviewed him a little over a decade ago, when he was involved in fighting a Florida law, backed by the National Rifle Association, that limited physicians’ ability to talk to their patients about gun safety.1
“This is not an even-steven discussion,” Alpert told me then. “This is child health against a paranoid fear about guns being taken away from someone.”
For Alpert, who died in 2013, gun control was a central focus of his career. As of 2011, it was not a central focus of his profession. Nowhere near it. I wondered whether and how that had changed as the relative threat of guns had grown, and what it might tell us about where we are headed.
It often feels like nothing changes. From year to year. From shooting to shooting. We’ve seen egregious inaction and even a doubling down, with talk of putting more firearms into our communities, not fewer, and a reiteration of the relentless myth of the safety granted by a good guy with a gun.
And yet, when I look back at Alpert’s work and the ongoing work of his colleagues, I see some things have changed. Not enough, but steadily, so that it is possible to see a trajectory that offers, dare I say it, a glimmer of hope.
Dr. Lois Lee put it bluntly. A Boston Children’s Hospital emergency medicine physician and chair of the American Academy of Pediatrics executive committee focused on violence prevention, Lee said that children have been killed and injured at a high rate by guns for a long time before her profession or the general public really acknowledged those injuries as a broad public health crisis.
She cared for many of those kids while training as a doctor in Philadelphia in the mid-90s, she told me. Many of them were—are—Black youth.
The rate of gun deaths among children have increased significantly in recent years across seemingly all pockets of the population, though not evenly. Those communities that are most affected by the increase are the same ones that have been harmed by gun violence for longest and most intensely, according to multiple recent analyses—namely, neighborhoods that are poor and predominantly Black.
While community organizations and faith groups have been working for decades to address gun violence in those neighborhoods, the fact is that the medical community as a whole really didn’t give it the attention it required.
“It was thought to be a problem of the inner city,” Lee said.
The American Academy of Pediatrics acknowledged the disparity in gun deaths among children in 1992, when it issued a policy statement on firearm injury prevention. But the statement’s recommendations didn’t do much to address it, calling broadly to “reduce the accessibility of handguns in the environments in which children live and play.”
Through much of the 1990s and early 2000s, a lot of the academy’s work on this topic was focused on parent education and counseling doctors on how to make gun safety part of the “anticipatory guidance” that they routinely offer patients: wear bike helmets, keep toxic household products out of kids’ reach, etc. —the very type of guidance that the Florida law sought to block.
In November 2012, the group updated its policy statement and went further this time, calling for “the strongest possible regulations of handguns for civilian use,” including a restoration of the ban on military-style semiautomatic weapons that Congress had allowed to expire in 2004. It reiterated that the best way to keep children and teens safe was to keep guns out of homes and communities.
Looking back, the timing seems uncanny, once again. A month later, a young man took his mother’s guns, including a semi-automatic rifle, killed her and then murdered 20 six- and seven-year-olds at Sandy Hook Elementary School, along with six school staff members. The national appetite for gun control seemed to grow.
“This was a different demographic than had been impacted before,” Lee said.
Physician organizations, including Lee’s, ramped up their lobbying work, but Congress failed to act.
Five years later—and many child gun deaths between—a shooter at Majorie Stoneman Douglas High School killed 17 people with a semi-automatic rifle and turned their peers into some of the most effective gun control advocates this country has seen.
“Since Parkland,” Lee said, “the dialogue has shifted.”
Today, there is little of the outspoken dissent that Alpert saw within the American Academy of Pediatrics membership, Lee said, and more concrete action. The group has convened advocates and lobbied for federal dollars for firearm injury research and community- and hospital-based violence prevention programs. It has created new public resources for talking about gun safety, with a focus not only on keeping guns out of the home—because more than 30 percent of American homes already have one—but also on safe storage when a gun is present, what Lee described as “layers of barriers” to prevent a curious 3-year-old or an impulsive teenager from gaining access. That means storing a gun unloaded, locked and separate from ammunition.
The group also fast-tracked the research and writing of its latest technical report and policy statement, published last year, in which Lee played a central role. This one called for a strategy of harm reduction at every level, in the home, community and government.
The list of recommendations is extensive. Among them:
Regulate firearms as a consumer product, similar to motor vehicles, with national standards for training, licensing and insurance overage.
Implement universal background checks, including for private sales and at gun shows.
Create new or standardized laws holding firearm owners liable if a child accesses a gun.
Ban semiautomatic military-style weapons and high-capacity magazines.
Increase funding and infrastructure for firearm injury research.
Push for advocacy and action by health care institutions and hospital systems.
Lee has been working on pediatric firearm injury prevention for a decade. She literally wrote the book on this topic. She has had more requests for interviews in the past two years than ever before. That makes her hopeful, she said, about where we may be headed. Though not about where we are.
“How is it,” she said, “that we’ve become a country with so much technology and so much science, and we are just accepting that firearms—something that’s so preventable—is our number one killer of our children?”
The history of the American Academy of Pediatrics’s approach to gun violence is interesting to me mostly as a case study within a broader cultural conversation.
Lots of leading medical associations in recent years began calling for a public health approach to this preventable crisis—despite the NRA mocking them and claiming that doctors should “stay in their lane.” Many groups across the broad spectrum of those lobbying for gun control also are using a public health approach, from Here 4 the Kids, which advocates for gun bans and buybacks, to 97 Percent, a group of gun owners who support universal background checks, among other gun safety measures.
That means shifting the conversation from individual actions to collective responsibility, said Sana Chehimi, director of policy and advocacy for the nonprofit Prevention Institute.
Violence in any form, Chehimi said, is preventable. “It is not inevitable,” she said. “That is at the heart of framing it as a public health issue.”
A lot of the institute’s work is focused on reducing upstream causes of gun deaths, including those by suicide. That means building connections across communities that have been most affected: making public spaces greener and safer, adding local employment opportunities, investing in libraries and other community resources, and finding other ways to bolster residents’ resiliency.
“What makes a community safe, and how do different communities define that for themselves?” she said. Having fewer guns in a community is an important factor.
For a long time, the story of the responsible gun owner—the idea that reasonable people should be allowed to have guns, and that guns themselves are not the problem—has been a powerful one in the public psyche, Chehimi said. But, she said, that narrative is simplistic and incongruous with what has actually happened, which is a largely unchecked proliferation of guns and a rise in gun deaths.
“We know that this is a narrative that we can defeat over time,” she said. “We’re starting to see that.”
Chehimi pointed to other once-controversial public health campaigns that have resulted in protections that are entirely accepted standards in our society, like the near-ubiquitous use of child carseats. Carseats were uncommon just two generations ago. Then, a pediatrician from Tennessee named Dr. Robert Sanders, who had witnessed too many preventable child deaths from motor vehicle accidents, lobbied in 1977 for the first-ever state law requiring them.2 The movement grew.
“The opposition to that was that it was going against parents’ individual rights to make decisions for their kids—of course they were safe drivers, and nothing was going to happen in the car,” Chehimi said. “And now we take that change for granted. I think there’s a similar tension that is happening right now, of why some of these policies are being resisted perhaps by folks like your Democratic governor.”
She’s talking about Janet Mills, the governor of Maine, where I live.
Mills has an A grade from the Sportsman’s Alliance of Maine, a powerful lobbying group that has been effective at blocking or minimizing state-level gun control measures for years.
In the alliance’s 2022 election questionnaire, Mills said she opposes requiring licenses to buy or possess a gun. She opposes restricting semiautomatic weapons or high-capacity magazines. She opposes requiring background checks for private sales.
In just the past year, Maine parents and educators, already reeling from school shootings across the country, have experienced active shooter hoaxes and threats of violence that sent schools into lockdown. We’ve learned that three guns used in the deadliest mass shooting to date in Canada were obtained in Maine through private transfers for which no background checks were required. We know that the majority of firearm deaths in Maine are suicides, and that Maine’s gun suicide rate is well above the national average. And, in April, Maine was added to the rolls of 2023 mass shootings when a man allegedly shot and killed his parents and their friends, then injured several more people in shootings on a highway off-ramp.3
Mills has not put forward a plan for leadership on gun safety or taken a public position on several bills now before the state legislature, including one requiring universal background checks. Just yesterday, the Democrat-controlled House voted down a bill that would have required a 72-hour waiting period on all firearm sales. The vote was close, 73-69, and there’s no sign that Mills provided support or political cover for Democrats that might have been on the fence.
I asked Mills’s office for an interview or, alternatively, for responses to a short list of questions, including whether the fact that firearms are now the leading cause of death among children has changed her position at all. A spokesperson acknowledged receipt of my request but did not provide responses or respond to follow-up emails.
I’m not naive. I know that the issue of gun control is infinitely more complicated and politically fraught than the debate over car seats ever was. But I also understand the power of what Chehimi called “catalytic events” that create the momentum that changes a society, and it is a painful truth that the next one is likely just days away.
For the past several years, Mills’s office urged Maine residents to follow the science and listen to public health experts when it came to protecting ourselves and our communities from coronavirus. It’s time for her and others in positions of power across the country to follow their own advice. Listen to the public health experts, including those who have dedicated their lives to caring for children and—finally, please—do something.
On the evolution of Between Us: It’s been a bit since I sent a newsletter. I can attribute that to a rush of book promotion around Mother’s Day and my husband’s busy travel schedule this spring, plus kid sicknesses and the end of year transition and the time I’ve spent trying to think through the next book project. Another piece of it is that I’m still trying to figure out what I want this thing to be. What I want any of this to be, really.
I wrote to a friend and writing hero recently looking for some specific ethical advice, and she gave it to me. But then she also asked me this: “What is the work supposed to be?”
Honestly, I don’t know. I’ve gone through a pretty significant career transition, from one unstable field (newspaper journalism) to another (publishing), while navigating early motherhood and pandemic parenting, and I’ve come out on the other side feeling pretty unsure about what the path ahead will look like, or how this newsletter will fit.
I plan to write more here about this uncertainty, what it feels like, the fear and the absolute joys I’ve found in it, too. I plan to write about a lot of things.
, another creative hero of mine who is also my neighbor, last week published an essay I love, about hustle vs. drive and how the time that writing takes collides with the money that must be made from said writing. After I spent months of hustling to promote Mother Brain, it was such a good reminder about what is required of me to to do good work, and how very different those things are from the hustle.So, I’m taking a break from social media for the summer and I’m making a plan for this to be a space for good work. Not as a weekly newsletter. As an as-it-happens newsletter. Which means sometimes it will arrive regularly. And sometimes it won’t. I hope you’ll read it anyway.
The American Academy of Pediatrics ultimately succeeded in blocking Florida’s law after years in court, though similar “gag laws” took effect in several other states.
The New York Times wrote in 1978 that Sanders “compared the auto death situation to that of an infectious disease, but said that in the case of a disease physicians and the public alike would demand immediate protection or immunization procedures.”
Two months later, no information has been released about how the alleged shooter obtained the gun(s), despite persistent questions from reporters in the state.
Chelsea, this essay is so good. I hope Mills's office follows up with you; I'd love for her to shift her position, although I'm not naive about it either. (And thank you for mentioning my essay!)