A public health response helped reduce fatal car wrecks in Texas. Can it do the same for gun deaths?

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When Mark Rosenberg started a branch of the Center for Disease Control to study violence in 1983, he decided to model his work on existing research about another rising cause of injuries and death — motor vehicle crashes.

At the time, wrecks were replacing infectious diseases as a leading cause of death in America. The federal government invested roughly $200 million a year to identify specific causes — and potential solutions.

That investment helped bring about a wave of innovations that made driving safer. Rosenberg pointed to several: Steering columns were redesigned so they no longer impaled drivers in front-end crashes. Airbags became standard features. New road design standards helped to reduce injuries and deaths across the country.

“With guns,” Rosenberg said, “we had hoped that we could do the same thing.”

But his CDC branch hit resistance from gun rights advocates, whose initial skepticism evolved into a calcified opposition. A congressional amendment in 1996 essentially thwarted the federal funding of gun violence research.

In 1999, the CDC fired Rosenberg.

In the quarter century that has followed, even the suggestion of approaching gun violence from a public health perspective has been stiff-armed by gun rights advocates.

“The right to keep and bear arms is guaranteed in our Constitution and has been affirmed by numerous Supreme Court rulings,” National Rifle Association Spokesman Billy McLaughlin said in a written statement for this story. “The efforts to treat firearms policy-related matters as a ‘health issue’ and comparisons of gun ownership to driving are politically motivated and misplaced.”

Many public health experts say if we understand what spurs violent acts, how people obtain guns, and how mishandling firearms can accidentally injure or kill, we might find a more agreeable path to industry-driven safety features. In other words, we made airbags and redesigned steering columns that save lives without taking away people’s cars.

“There’s an appetite in the public and among policymakers right now for valid information,” said Andrew Morral, a behavioral scientist at the RAND Corporation, a nonpartisan research institute.

Instead, policy discussions have often taken on a much more divisive tone. Perhaps nowhere is that more clear than in Texas, which despite its reputation as a Second Amendment sanctuary, ranks in the middle of all states in gun ownership. In the last decade, the state also has been home to at least eight mass shootings that collectively killed more than 100 people. At times, even the most conservative politicians have called for “common-sense" solutions.

Most legislative debate has centered around who can access guns. The conservative majority has made buying and publicly carrying firearms easier over the last decade while eschewing attempts to expand widely supported background checks and limits on some sales. Democrats’ most prominent recent proposal has been to prevent people under 21 from buying semi-automatic rifles.

During that time, gun deaths kept climbing. By 2020, the rate at which Texans died from gunshots slightly surpassed the rate of deaths from car wrecks, marking the first time since the mid 1990s that guns were more likely than vehicle crashes to kill Texans. The situation is even more pronounced for people who are 19 and younger.

“How can we make owning a firearm safer? How do we put firearm safety as the No. 1 priority for firearm owners, firearm retailers, firearm manufacturers?” said Sandra McKay, a professor of pediatrics at the McGovern Medical School at UTHealth Houston and a gun owner.

Scientists who study violence and health say the U.S. must robustly research gun violence to stop what has become a leading cause of death, especially for young people.

One team of scientists from the University of Michigan and Brown University studied the vast funding differences between research on firearm injury prevention and other top causes of death among young people. They stressed the need for more government-funded studies.

“No serious health threat in the past hundred years has been solved without such federal investment,” they wrote.

• • •

In 1981, more than 30 people per 100,000 Texas residents died in motor vehicle crashes. That was the highest fatality rate in recent history. At the time, motorists and their passengers weren’t required to wear seatbelts. Driving while drinking remained legal.

As Rosenberg was getting the violence arm of the CDC up and running, Texas lawmakers’ attitudes about driving laws were evolving. But change was still slow on many fronts. In 1985, state legislators passed a law backed by officials with the Department of Public Safety and the then-Department of Health that required people in the front seats of vehicles to wear seat belts.

Authorities said fewer people died in car crashes the first month after the law went into effect — even during a grace period when they were not yet enforcing the new law with citations, according to an Associated Press news report that year.

By then, data and research had made clear that seatbelts helped reduce severe injuries and deaths, many of which were caused by people smashing into or through parts of a vehicle in crashes.

While people in Massachusetts collected signatures for a referendum to repeal a seat belt law there, Texas state police praised the newfound safety measure and Texans were a national leader in compliance.

“Despite Texas’ rapid rate of growth, the death toll in 1985 was more than 1,000 beneath Texas’ all-time record traffic death count of 4,701 in 1981,” Jim Adams, the state’s public safety director said in April 1986.

He credited the new seat belt law and stronger enforcement of driving while intoxicated laws.

But those laws did not touch what had become a pastime in the state: wrapping one hand around a steering wheel and the other around a cold beer.

In 1982, more than one-third of the nation’s deadly traffic incidents involved a drunk driver, according to the National Highway Traffic Safety Administration. The next year, Texas A&M University began studying the role of alcohol in fatal car crashes in Texas. In their examination of fatalities over a four-year period, researchers found that roughly half of the drivers they examined were legally intoxicated when they died. They also learned that crashes often occurred late at night and early in the morning.

The lethal dangers of drinking and driving was blatant to many who supported stricter laws in Texas, but not to enough lawmakers.

For multiple legislative sessions, lawmakers tried to prohibit drinking while driving, even if the motorist wasn’t legally intoxicated. Bills often stalled in committee, never reaching a full chamber vote. Such a prohibition finally passed in 1987. But the law’s limitations soon became clear.

“The current law is a farce,” then-state Rep. Fred Hill, a Richardson Republican, said in 1991, according to the Austin American-Statesman. “You can avoid the open container law by just handing your open container of alcohol to a passenger when you see the flashing lights in the rear-view mirror.”

Police agreed — the law was hard to enforce. Hill filed a proposal to also stop passengers from drinking. But that went too far, according to the representative who chaired the committee where the bill was headed.

“Some of these folks who get concerned about drinking and driving actually would rather see alcohol banned altogether,” Democratic chair Rep. Ron Wilson of Houston said at the time.

It would take another 10 years for the Texas Legislature to ban open alcohol containers in the passenger areas of vehicles. And it wasn’t until 2009 that lawmakers required all passengers in vehicles to wear a seatbelt. By 2011, the rate of people dying in Texas car accidents had dropped to 12.3 people per 100,000 residents — the lowest it had been in nearly 50 years.

• • •

As research and data helped bring progress in fighting motor vehicle deaths, the CDC began to distribute money to fund gun research.

Two such investigations, published in the New England Journal of Medicine in 1992 and 1993, linked guns in a home to increased risks of suicide and homicide by a family member or intimate acquaintance, Rosenberg said.

The 1992 paper concluded firearms owners should “weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.”

The 1993 study identified a history of fighting and drug use as risk factors for homicide inside of a home and concluded: “Rather than confer protection, guns kept in the home are associated with an increase in the risk of homicide by a family member or intimate acquaintance.”

Pushback to Rosenberg’s work quickly escalated. The research even drew scrutiny from medical experts who did not buy into the idea that gun violence was a public health issue. Others felt the research was limited and did not account for all variables relevant to violence.

"If by the disease model, you try to isolate the violence and treat the violence, like they isolate a germ and treat a germ, they will fail," a doctor told the Associated Press in 1993. "Violence is a byproduct of the social conditions. … They have to treat the cause."

The National Rifle Association saw the research as a campaign to take people’s guns. By the early 1990s, NRA representatives dismissed the CDC’s research as fraudulent and said researchers were finding what they were looking for, not conducting science.

“They strongly believe that guns are bad and that gun control is good,” one NRA representative told the Atlanta Journal-Constitution in 1993. “They have this innate faith, and their faith is leading them to eschew competent science for anything that reaches that predetermined conclusion."

In the spring of 1996, gun rights advocates, including the NRA, asked a U.S. House committee to discontinue $2.6 million that Rosenberg’s branch was spending on gun research — about one-tenth of the $25 million allocated to violence research from the CDC’s $2 billion budget that year.

U.S. Rep. Jay Dickey, an Arkansas Republican, obliged.

He offered an amendment in a congressional spending bill, commonly referred to as the Dickey Amendment, requiring that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

For decades after that, lawmakers interpreted the amendment to mean that no federal funds could be used on gun violence research.

Three years after the Dickey amendment was adopted, Rosenberg was fired from the CDC. He said lawmakers, under pressure from gun rights groups, in turn put pressure on his boss to end the work.

• • •

By the time Dr. Patrick Carter became interested in studying gun deaths, a chilling effect had crystallized.

He was working in an emergency room in Michigan, distressed by the number of patients arriving with gunshot wounds.

Against the advice of mentors who saw a lack of research funding as an inhibitor to career security and growth, he joined the tiny ranks of gun-injury researchers whose work was largely financed with private money. He remembers having about a dozen such contemporaries when he began 15 years ago.

“Imagine if we had 12 researchers in the field doing cancer research,” Carter said recently. “Where would we be?”

He now co-leads the Institute for Firearm Injury Prevention at the University of Michigan. Carter’s research included a study that compared federal funding allocated to the leading causes of child deaths in the U.S. from 2008 to 2017.

Using various federal sources and databases, the team calculated that on average, $88 million a year went to study motor vehicle crashes, then the leading killer of American youth. The third-leading cause of death, cancer, received roughly $335 million a year.

At the time, the second-leading cause of death among children was gunshots. Firearm injury prevention research among children and adolescents received about $12 million a year.

Such little funding, the study found, resulted in fewer scientific articles than the rate of gunshot injuries and deaths would suggest. The lack of research has led to a gap of information about a problem that is now the leading cause of death for American youth.

“A thirtyfold increase in firearm injury research funding focused on this age group, or at least $37 million per year, is needed for research funding to be commensurate with the mortality burden,” the researchers concluded. “The current health of U.S. children is largely the result of a century’s worth of investment in improved living standards, public health, science and technology, and advancements in the practice of medicine.”

• • •

Years after being fired from the CDC, Rosenberg eventually formed a friendship with the unlikeliest of people: Dickey, the federal lawmaker who called himself “the NRA’s point person in Congress” and whose amendment frosted gun violence research.

After leaving Congress in 2000, Dickey’s views about researching gun violence evolved. In 2012, the two men co-authored a Washington Post opinion piece advocating for more federal funding to understand the matter better.

“We were on opposite sides of the heated battle 16 years ago, but we are in strong agreement now that scientific research should be conducted into preventing firearm injuries and that ways to prevent firearm deaths can be found without encroaching on the rights of legitimate gun owners,” they wrote. “The same evidence-based approach that is saving millions of lives from motor-vehicle crashes, as well as from smoking, cancer and HIV/AIDS, can help reduce the toll of deaths and injuries from gun violence.”

Dickey died in 2017, but the campaign the two began gained traction as Rosenberg continued it with Dickey’s former wife.

With a 2018 spending bill, Congress said the federal government can study gun violence so long as it’s not promoting gun control. A year later, $25 million was earmarked for the study of gun violence.

“It’s at a very low level, but it’s important that it’s there and hopefully we can make the case that doing the research is not going to result in everybody losing their guns,” Rosenberg said. “In fact, it may result in everybody keeping their kids, husbands and families alive.”

• • •

Gun violence in Texas started climbing at the beginning of the last decade. But the Legislature focused on increasing access to guns. In 2015, lawmakers approved legislation that allowed people to carry handguns on college campuses.

Then in August 2019, 31 people were killed in mass shootings in El Paso and Midland-Odessa, incidents that were separated by 28 days. Forty-seven others — including three police officers — were wounded.

After the shootings, Gov. Greg Abbott and Lt. Gov. Dan Patrick said they were open to some gun restrictions. Abbott suggested the Legislature consider ways that would make it easier and cheaper for private firearms sellers to voluntarily run background checks on customers.

Patrick went further. He said he was “willing to take an arrow” and defy the NRA to close the background check loophole that enabled ineligible gun buyers, like convicted felons, to purchase firearms through stranger-to-stranger sales that don’t vet them.

"When I talk to gun owners, NRA members and voters, people don't understand why we allow strangers to sell guns to total strangers when they have no idea if the person they're selling the gun to could be a felon, could be someone who's getting a gun to go commit a crime or could be a potential mass shooter or someone who has serious mental issues,” Patrick told The Dallas Morning News in September 2019. “Someone in the Republican Party has to take the lead on this.”

Their support for more background checks seemed to vanish by the time the 2021 legislative session began. Instead of closing loopholes, the Legislature passed a law that allows people to openly carry a handgun without a permit or training.

Nicole Golden is the executive director of Texas Gun Sense, which advocates for policies that would make gun ownership safer — but also respects Second Amendment rights. She said current, accurate data about firearms and violence could help her group lobby for some moderate measures. But, she noted, there are additional obstacles to passing effective policies — like the lack of political will.

“There’s a lot more we could do if we prioritize this — if our leaders prioritize this to say, you know, ‘Hey, we’re going to find out everything we can find out about who’s being shot in Texas,’” Golden said. “And then tailoring our approaches around that.”

Gun safety advocates say permitless carry laws like Texas’ are a regressive response to an ongoing crisis: making guns easier to access rather than safer to own. It’s a different approach than Texas officials took when deaths from car wrecks were climbing.

“When it comes to guns, which along with automobiles are the single most lethal consumer product that’s sort of ever been unleashed on the American people, policy makers are doing the exact opposite,” said Peter Ambler of the Giffords Law Center to Prevent Gun Violence.

Another mass shooting loomed large over lawmakers when they returned to the Capitol this year. In May 2022, an 18-year-old gunman killed 19 elementary students and two teachers in Uvalde. It was the deadliest school shooting in Texas history.

State Rep. Tracy King and Sen. Roland Gutierrez, two Democratic lawmakers who represent Uvalde, launched an uphill battle to pass legislation that would have raised the age someone must be to buy semi-automatic rifles. Families of children slain in the Robb Elementary School shooting routinely visited the Capitol to lobby for the legislation.

It ultimately failed.

Lawmakers pitched at least five bills to address the loophole Patrick said he wanted fixed in 2019. Only one received a public legislative hearing. None advanced to a full chamber vote.

• • •

Forty years after Rosenberg and his colleagues set out to better understand injuries and deaths from gunshots, the dearth of information about firearms violence stands in stark contrast to the nation’s response to motor vehicle-related injuries and deaths.

No federal agency tracks all gun-related injuries. Some groups, like the Gun Violence Archive, track incidents in a public database. But no abundance of continuous gun-related research serves as a foundation for more research and innovation that can instruct public policy.

The cost of gun violence is staggeringly high. One study published last year in the Journal of the American Medical Association estimated firearm injuries create a $557 billion economic toll every year.

Rosenberg still has hope. After four decades of trying to convince the country that public health approaches could help address gun violence, he now identifies the issue as everyone’s crisis: mothers and fathers, police and judges, teachers and any person who cares about anyone else.

Even in gun-loving Texas, firearm control and safety advocates noticed some small openings for debate this year and found middle ground in policy decisions with people who want to ensure Second Amendment rights aren’t infringed.

Rosenberg recently recounted something a longtime friend, the former CDC director who recruited him to start the studies, tells him.

“The biggest public health threat these days is not actually overdoses and drugs, it’s not gun violence, it’s not COVID,” Rosenberg said. “The biggest threat is fatalism — when people start to think there’s nothing I can do about this.”