Garen Wintemute recalls weaving through rows of tables that displayed thousands of assault rifles, semiautomatic pistols, submachine guns, ammunition and body armor. He wasn’t shopping for guns. He just moved at a steady, slow clip, avoiding eye contact and hoping that no one would notice him. Mostly, they didn’t.

“Just classic field epidemiologic work,” he says of his research at gun shows.

Wintemute, a professor of emergency medicine and director of the Violence Prevention Research Program at UC Davis, attended 78 gun shows in 19 states across the country, mostly between 2005 and 2008. He has turned his observations into an extensive report and a series of policy recommendations.

Wintemute has dedicated his career to preventing firearm deaths—a problem that has held steady at epidemic proportions in the United States for more than a decade and accounts for an average of 30,000 deaths each year.

Gun deaths tend to get separated into two discrete categories: interpersonal violence (homicide), which accounts for about 39.5 percent of the deaths, and self-directed violence (suicide), which accounts for 60.5 percent.

Traditionally, suicide is understood as a mental health issue and interpersonal violence as a criminal justice issue. “One of the major contributions of the public health approach was to say, let’s aggregate these traditionally disaggregated problems by the common denominator that they share, which is the involvement of a firearm,” Wintemute says. Considering the problems together allows, he says, “a broader view of the problem, to consider solutions that might apply to both interpersonal and self-directed violence, and otherwise would be harder to see.”

Wintemute’s background in emergency medicine informed the public health approach to preventing gun violence that he uses in his research. “Arguably, physicians have an obligation—they certainly have the opportunity, if they choose to take it—not just to focus on the patient who’s in front of them, but to focus upstream and on the flow of events that brought that patient to them, and intervene up there,” Wintemute says.

The public health approach also trains the eye to look beyond individual patients, toward their social and physical context. Gun violence, like infectious and chronic diseases, is a product of the environment. A public health approach identifies which part of the environment is causing the illness and changes or eliminates the source of the illness. [pullquote]“There was no money. There was active opposition. The work was risky,” says Wintemute, who has experienced personal threats throughout his career. [/pullquote]

Through this lens, Wintemute has been able to discern populations at high risk for gun violence that were otherwise overlooked. For instance, while a mass killing prompts the most public scrutiny of the country’s gun policies, Wintemute points out that such events are relatively rare. Compiling the number of fatalities from the most deadly shooting events in recent years—Virginia Tech, Sandy Hook, Fort Hood, the Washington Navy Yard and Aurora, Colo.—shows that a total of 96 people were killed. Between 2003 and 2012, nearly that many people died from gun violence in America every day. The goal, he explains, is to provide evidence-based solutions that could help prevent guns from getting into the hands of the most dangerous people.

 

Wintemute began his career practicing emergency medicine, first as an ER physician in Northern California, then in a refugee camp on the Thai-Cambodian border. It was shortly after the end of dictator Pol Pot’s reign, and the daily toll of violence was inescapable. After re- turning to the United States in the early 1980s, Wintemute decided to pursue a career in international health. He enrolled in the master of public health program at Johns Hopkins University.

In September 1982, Stephen Teret, who had worked previously as a lawyer, was a relatively new professor at Johns Hopkins. He remembers the first day he had Wintemute in a class: “I was standing in front of the classroom teaching, and Garen was this crazy young guy leaning his chair against a wall—and it was an injury prevention class.” Teret was not impressed.

But Teret’s impressions quickly changed, and the doctor and the lawyer began to collaborate. Wintemute was undergoing a transformation. Originally driven to practice international and refugee medicine, Wintemute began to consider the reverberations of violence—firearm violence, in particular—in the United States.

At that time, Wintemute recalls, there was no federal or foundation support for the work, and by the mid-1990s, even the Centers for Disease Control and Prevention had lost its funding for research into firearm violence—a result of political opposition in Congress, he says.

“There was no money. There was active opposition. The work was risky,” says Wintemute, who has experienced personal threats throughout his career. “But as a result of all those things, there was intellectual freedom. The field was essentially unoccupied; it was a chance to be a pioneer.”

Wintemute jotted down the pros and cons of his original plan of working in international health versus injury prevention. He keeps that piece of paper filed away in his single-story office building, which lies just down the path ambulances take to and from the UC Davis Medical Center.

Wintemute and Teret decided to collaborate and focused their early efforts on gun manufacturers. Given the high rate of firearm deaths, Teret says that company decisions about the design, marketing and distribution of guns should be considered as health-policy decisions. In other words, “we needed to let people know that guns are not a naturally occurring phenomenon.” Companies make them, sell them and convince people to buy them. To get that point across, the pair borrowed a method
commonly used in other areas of science and advocacy.

“In environmental health, people talk about point-source pollution—if you had to imagine a picture, it would be a smokestack that’s belching filthy dust into the atmosphere or a pipe that’s dumping raw sewage into a stream or river,” Teret explains. “We thought that there was a point-source pollution with regard to guns: the loading platforms of these factories, where the guns— millions of them each year—enter the stream of commerce.”

Armed with a camera and little else, Wintemute and Teret traveled from Baltimore to the so-called Gun Valley of the United States, a swath of western Massachusetts and Connecticut where gun factories have been operating since the 1800s. “Driving around these factories, we assumed correctly that we would not be welcome guests,” Teret recalls. Teret drove while Wintemute snapped photos.

Decades later, Wintemute employed a similar tactic while researching gun shows. There was no doubt that his camera would be unwelcome, so he concealed it in a candy bag that he tucked under his arm, and blindly shot photos, hoping they’d come out. He also realized that everybody talked on cell phones— so he devised a plan to dictate his observations into his own voicemail.

The camera again proved to be critical. Without it, Wintemute says, he didn’t think people would believe his stories— in particular, the blatant and widespread practice of illegal gun sales involving surrogate or “straw” purchases. “Nobody thought anyone was watching. Nobody thought that they had a risk of getting caught,” he says. “All this stuff happened right out in the open.”
[pullquote]In documenting the widespread practice of straw purchasing, Wintemute was struck not only by how frequently these transactions occurred, but by how indiscrete they were.[/pullquote]

Wintemute’s research helps explain an apparent paradox in sourcing guns used in crimes. Investigations of illegal gun trafficking have found gun shows to be an importance source of these guns, according to evidence gathered by the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) and other agencies. At the same time, surveys conducted by the Bureau of Justice Statistics have found that less than 2 percent of felons convicted of crimes involving firearms acquired those guns themselves at a gun show.

Straw purchasing can explain some of the discrepancy. Straw purchasers are hired to buy firearms on behalf of people who are either unwilling or unable to buy them under their own names. The actual buyers may be prohibited from doing so—due to felony convictions, for example—or they may not want their names associated with the purchase—in the case of gun traffickers, for example.

In documenting the widespread practice of straw purchasing, Wintemute was struck not only by how frequently these transactions occurred, but by how indiscrete they were. Straw purchasing is a felony under federal law, but buyers and sellers appeared to operate with a sense of impunity.

Wintemute recalls one such transaction he witnessed in Albuquerque, N.M., where the actual buyer had the driver’s license of the straw purchaser and was filling out the paperwork himself. (Usually, the real purchaser would not be quite so obvious, Wintemute says.) When he turned the papers over to the retailer, she asked for additional information. The real purchaser openly called out to the straw purchaser: “Hey, what’s your middle name?” And then: “How do you spell that?”

Wintemute says that the retailer watched all of this.

“She goes, ‘I shouldn’t.’ And she does,” he says. “Felony for her. Felony for those guys. But nobody’s watching. Except me.” There’s another way to get around the law with far less deception: private party sales.

In most of the country, firearm transfers between two private individuals are by law anonymous and undocumented. Sellers are not required to initiate a background check, unless they suspect that they are selling to a prohibited per- son. (California is an exception: Private parties must physically pass their guns through a licensed retailer, who runs background checks and registers the gun before transferring it to the buyer.)

So, no one asks.

“Something like 40 percent of all firearm transfers occur between private parties. No waiting period, no background check, no records,” Wintemute says. “Everybody understands that is anonymous, undocumented commerce, and that’s what they’re looking for.”

The majority of people convicted of violent crimes involving guns obtained their firearms this way, according to data from the Bureau of Justice Statistics. More than 85 percent of recovered crime guns traced by the ATF have gone through at least one private party transfer.

Wintemute recommends that background checks be universally mandatory for such transactions. In many states, there is no consequence for the seller if he or she transfers a gun to a prohibited person.

“Let’s say I’m a prohibited person and I’m buying the gun from you. It’s a crime for me to buy that gun, but I’m going to go do badness with it anyway; we get that,” Wintemute says. “It’s only a crime for you to sell me the gun if you, to quote exactly, ‘know or have reasonable cause to believe’ that you’re selling the gun to a prohibited person.”

Despite all the criminal activity he documented at the gun shows, Wintemute says he was never totally outted, but he did have a few close calls.

The researcher in him was enthralled as he happened upon a scene he identified as a straw purchaser buying weapons to support drug trafficking. One person among a group of men was buying half a dozen guns, at $800 to $900 each. “I’m taking pictures and I’m so focused on hoping the pictures are going to come out okay that I wasn’t paying attention,” he says.

But Wintemute’s girlfriend, who is also a researcher on this topic, was paying attention. She subtly told him to get away. “I look up and they’re all looking at me. And they’re yelling, ‘He’s taking pictures.’”

Wintemute disappeared into the crowd, and his girlfriend made her exit separately.

“The five guys whose photographs I had been taking stop right in front of her and had a discussion about what they were going to do [to me] when I came out,” he says. “It was a short story with a terminal ending.”

 

Nowadays, Wintemute is engaged in research that is decidedly less risky, such as his work tackling the appropriate role of mental illness diagnoses in gun legislation. His goal hasn’t changed, though: He wants to educate policymakers and inform evidence-based decisions about how to reduce gun violence.

The current federal rule governing mental illness and gun ownership is based on the Gun Control Act of 1968, which prohibits any person who has been “adjudicated as a mental defective” from obtaining a firearm.

“Everybody who works in the field, whatever side of the gun issue they’re on, agrees that the current federal standard is a disaster. It’s 50 years old and it’s based on thinking that’s even older than that,” Wintemute says. The Obama administration has made some updates, he adds, but still “it needs to be rewritten.” [pullquote]“What I hope to be able to say—implicitly or explicitly—is, ‘These people look just like you, Senator.’ I want people in policy to realize that people like them die, too.” [/pullquote]

Although mental health has become a major buzzword in the national dialogue about gun violence, Wintemute and others have pointed out that the presence of mental illness alone is not a risk factor for violence. “By itself, mental illness is not a big problem. Couple mental illness with alcohol abuse, drug abuse, violence—it becomes a big problem.”

A 2013 report by the Consortium for Risk-Based Firearm Policy, which both Wintemute and Teret participated in, recommended that states temporarily restrict access to guns based on risky behaviors—separate from a mental illness diagnosis—and provide a way to temporarily seize firearms from someone exhibiting such behaviors.

Lindsey Zwicker, a staff attorney at the Law Center to Prevent Gun Violence—which also participated in the consortium—says that the report’s findings contributed to the drafting of the newly adopted Gun Violence Restraining Order (GRVO) law in California. “One important thing that came out of this—[especially] given all the dialogue around mental health and its role in gun violence—is that a mental health diagnosis in and of itself does not mean that somebody is more likely to commit violence,” Zwicker says.

“There’s no mention of mental illness or mental health in the law,” she continues. “All the factors that the court must consider when deciding to issue a gun violence restraining order are associated with past behaviors that would clearly mark somebody as a high risk…of committing violence in the future.”

Although California lawmakers were already working with the concept, the law was not enacted fast enough to stop the 2014 killings in Isla Vista, the student enclave bordering the UC Santa Barbara campus.

Elliot Rodger’s parents had seen the warning signs and were terrified: The 22-year-old had circulated a “manifesto” by email and posted an online video detailing his plans for violence. He had recently—and legally—purchased several firearms. His parents asked law enforcement to intervene; sheriff’s deputies visited Rodger at his Isla Vista home, but there was nothing they could do. Soon after, Rodger killed six people and injured more than a dozen people, before committing suicide.

The GVRO law addresses a gap in the existing law that restricts firearm possession by at-risk individuals. In California, a person is denied access to guns if he or she is deemed a risk to themselves or others, and is placed on an involuntary psychiatric hold—known commonly by its section number in the state’s welfare code: 5150. The sheriff’s deputies who checked on Rodger had determined he did not meet the 5150 criteria, and so the existing intervention did not apply.

“There are people—doctors know about it, mental health professionals know about it, cops know about it— who do not meet 5150 criteria, but something is just wrong here,” Wintemute says. “Making threats, drinking more, acting out, being violent—not enough to take them downtown, but something is really wrong.”

Beginning in 2016, law enforcement or family members can ask a judge to temporarily restrict someone’s access to guns. This restriction operates much the same way as a temporary restraining order for a domestic violence situation.

“The judge can say there’s a lot of evidence of trouble—and lots of risk for harm in the next few days,” Wintemute says. “We don’t understand exactly what to do to make all of this better. But while we’re figuring that out, let’s take the guns out of the equation.”

Sometimes, it’s the simple calculations that can be the most revelatory and, Wintemute hopes, impactful.

In a recent study, Wintemute analyzed current trends in firearm-related deaths, primarily based on data from the Centers for Disease Control and Prevention. His study confirmed that, while the overall death rate has remained the same, firearm homicide has been trending downward, but firearm suicide has been rapidly rising. In 2012, nearly two-thirds of all firearm deaths were suicides, and were especially prominent among white men. Correcting for population growth, Wintemute found that the firearm death rate had increased 29.1 percent among white males age 35 to 64.

“The surprise was how quickly suicide is increasing,” Wintemute says. “I had a feeling this would be true, but I wasn’t ready for the extent—firearm violence is becoming an old white guy problem.”

At the same time, the study confirms that the rate of firearm homicide remains disproportionately higher among young black men: In 2012, firearm homicide was the leading cause of death for black males age 15 to 24.

“In emphasizing the importance of suicide, and in emphasizing how many deaths come from middle-aged and older white men, I am in no way trying to take away from the importance of the fact that young black men are highest risk,” Wintemute says. “What I hope to be able to say—implicitly or explicitly—is, ‘These people look just like you, Senator.’ I want people in policy to realize that people like them die, too.”

By considering both firearm homicide and suicide as part of the same equation, Wintemute hopes to change the calculus.

“We have all become very familiar with the phrase ‘black lives matter.’ And I believe—I can’t prove it in any quantitative way, but I have lived this story now for a long time—that one of the reasons we’ve made so little progress on firearm violence is because the people who make policy look at the people who they see to be at risk and think, ‘Those people aren’t like me.’

“It’s easy to ignore, it’s easy not to commit personal resources to something that is perceived to be happening at a distance—whether that distance is geographic or social. What I’m trying to do with the suicide part is minimize the social difference between the people who make decisions and the people who are affected by those decisions.”