Correspondence
Firearms kill more than 30 000 Americans annually. 1 Although federal law requires licensed gun dealers to undertake b ackground checks on people who purchase guns, private sales at gun shows and online are exempt from these checks. Universal background checks for gun purchases could substantially reduce the number of gun-related deaths in the USA.2,3 Despite strong public support for universal background checks (92% of 1446 people polled in one survey),4 Congress has failed to act. Some researchers have argued that this disconnect between public opinion and legislation is attributable to a gap in engagement between supporters and opponents of stronger gun control.5 But could it be that public misperceptions of existing gun control laws also contribute to the absence of public mobilisation for new legislation? To answer this question, we undertook a nationally representative survey through the 2014 Cooperative Congressional Election Study (n=1384). Although the American public supports strong gun control laws, many people erroneously believe that these laws have already been enacted and do not support new legislation. 77% (95% CI 75–79) of Americans favoured universal background checks, yet only 53% (51–56) reported preferring stricter gun control laws. This difference might be attributable to poor awareness of the limitations of existing laws. We found that 41% (38–43) of Americans believed that universal background checks are already required by federal law, whereas 47% (44–50) correctly reported that a federal background check is required only for some gun purchases, and 12% (10–14) believed that no federal background checks are required. Among those people who strongly supported universal background checks, correct information about www.thelancet.com Vol 387 January 16, 2016
existing laws predicted support for stricter gun laws. Whereas 74% (95% CI 69–79) of those who incorrectly believed that the USA has universal background checks supported stricter gun laws, 89% (86–92) of those who knew that some gun sales do not require background checks supported stricter laws. We recorded no such relation among those who did not strongly favour universal background checks. We also identified evidence of an engagement gap: among voters who thought gun laws should be less strict than at present, 71% (95% CI 65–78) said they would never vote for a political candidate who did not share their position on gun control, compared with just 34% (30–37) of those who support stricter gun laws. However, the role of policy misperceptions in this domain is not well studied. Public education about the limits of existing laws could be an important way to mobilise support for new legislation. The survey was funded by the Yale Institution for Social and Policy Studies and the Yale Center for the Study of American Politics. We declare no competing interests.
*Peter M Aronow, Benjamin T Miller [email protected] Department of Political Science (PMA, BTM), Institution for Social and Policy Studies (PMA), and Department of Biostatistics, Yale School of Public Health (PMA), Yale University, New Haven, CT 06520, USA 1
2
3
4
5
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Fatal injury reports, 1999–2013, for national, regional, and states. Jan 22, 2015. http://webappa.cdc.gov/sasweb/ncipc/ datarestriction_inj.html (accessed March 30, 2015). Fleegler EW, Lee LK, Monteaux MC, Hemenway D, Mannix R. Firearm legislation and firearm-related fatalities in the United States. JAMA Intern Med 2013; 173: 732–40. Webster D, Crifasi KC, Vernick JS. Effects of the repeal of Missouri’s handgun purchaser licensing law on homicides. J Urban Health 2014; 91: 293–302. Quinnipiac University Polling Institute. July 3, 2014. http://www.quinnipiac.edu/ images/polling/us/us07032014_ulps31.pdf (accessed March 30, 2015). Schuman H, Presser S. Attitude measurement and the gun control paradox. Public Opin Q 1977; 41: 427–38.
Neglected tropical diseases in the Sustainable Development Goals Neglected tropical diseases (NTDs) have been formally recognised as a target for global action towards the Sustainable Development Goals. So can we now get rid of the word neglected? Not yet. Strangely, the NTDs were only a late addition by the Inter-Agency and Expert Group on Sustainable Development Goal Indicators to target 3.3—to “end the epidemics of HIV, tuberculosis, malaria and neglected tropical diseases” by 2030.1 WHO’s proposed NTD indicator— the number of people needing interventions against NTDs—captures a broad set of existing targets with political endorsement by the World Health Assembly, including 11 goals to eradicate or eliminate diseases.2 This indicator counts more than a billion people in low-income, middle-income, and even high-income countries. The proposal of this global NTD indicator shows an aspiration to deliver a package of interventions centred on the poorest and most marginalised populations. I am of course pleased that the Inter-Agency and Expert Group has given a permission to go ahead with our indicator at its second meeting on Oct 26–28, in Bangkok.3 The exclusion of NTDs from the list of indicators for target 3.3 would have been an early setback to the pledge to “leave no one behind”.4 But the inclusion of NTDs is no guarantee of success. The NTD community needs to continue to think outside of the box—the box numbered 3.3. WHO’s Department of Control of Neglected Tropical Diseases has been promoting not only the NTD indicators but also NTD tracers of equity relevant to other Sustainable Development Goal targets. These tracers of equity were proposed as a contribution of the NTD community to monitor equity
Rick Barrentine/Corbis
Policy misperceptions and support for gun control legislation
See Editorial page 200
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
223
Correspondence
and fairness in progress toward other Sustainable Development Goals and targets, including universal health coverage (target 3.8), universal access to safe water (target 6.1), and sanitation (target 6.2).5 These tracers are essential to monitor equity precisely because NTD endemic populations are the least likely to have access to these services at present.6 I do not share the opinion that the main outcome for the inclusion of NTDs within the Sustainable Development Goals would be more money for NTDs.7 Inclusion of NTD indicators and tracers will, on the contrary, help to maximise returns on investment in a broad portfolio of Sustainable Development Goal targets. Inclusion will help to identify the communities that have the greatest need for attainment of these goals: the populations that are the furthest behind in terms of development. I declare no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Dirk Engels [email protected] Department of Control of Neglected Tropical Diseases, World Health Organization, 1211 Geneva 27, Switzerland 1
2
3
4
5
224
Transforming our world: the 2030 agenda for Sustainable Development. United Nations. 2015. http://www.un.org/ga/search/view_doc. asp?symbol=A/70/L.1&Lang=E (accessed Nov 19, 2015). Second meeting of the Inter-Agency and Expert Group–Sustainable Development Goal. Bangkok: Oct 26–28, 2015. http://unstats. un.org/sdgs/meetings/iaeg-sdgs-meeting-02 (accessed Nov 18, 2015). Ban Ki-moon. Opening remarks to the media following the Summit for the Adoption of the Post-2015 Development Agenda. UN Headquarters, Sept 25, 2015. http://www. un.org/apps/news/infocus/sgspeeches/ statments_full.asp?statID=2751#.Vkx2fXYvfIU (accessed Nov 18, 2015). WHO. World Health Assembly (WHA) Resolutions on Neglected Tropical Diseases: 1948–2013. http://www.who.int/neglected_ diseases/mediacentre/resolutions/en (accessed Oct 20, 2015). Methodological note: proposed indicator framework for monitoring SDG targets on drinking water, sanitation, hygiene and wastewater. Geneva: World Health Organization and United Nations Children’s Fund. http://www. wssinfo.org/fileadmin/user_upload/resources/ Statistical-note-on-SDG-targets-for-WASH-andwastewater_WHO-UNICEF_21September2015_ Final.pdf (accessed Oct 6, 2015).
6
7
Water, sanitation, and hygiene for accelerating and sustaining progress on neglected tropical diseases: a global strategy 2015–2020. Geneva: World Health Organization, 2015 http://apps. who.int/iris/bitstream/10665/182735/1/ WHO_FWC_WSH_15.12_eng.pdf?ua=1 (accessed Oct 6, 2015). Horton R. Offline: The “chronic pandemic” that just won’t go away. Lancet 2015; 385: 758.
Methadone for prisoners Research by Josiah Rich and colleagues (July 25, p 350)1 shows that forced methadone withdrawal in prisons is associated with substantial individual and societal costs. These costs might be tolerable if a sound clinical or correctional rationale existed for forced withdrawal, but it does not. Retributivists might argue that criminal offenders should be punished for their wrongdoing, whereas providing methadone treatment rewards it.2 However, incarcerated offenders are already receiving punishment. Requiring prisoners to cease methadone treatment forces them to endure the physical and psychological burdens of opiate withdrawal in addition to those of imprisonment. This amounts to a double punishment and is inconsistent with the core principle of proportionate punishment that governs retributivism. Hardline anti-drug campaigners might argue that we should avoid treatments that seek to mitigate symptoms by replacing one addiction with another. 3 Instead, the goal should be abstinence from all drugs. However, evidence suggests that forced withdrawal rarely produces the long-term cure that such campaigners seek.4 For other medical disorders, clinicians and patients often opt for symptomatic relief when an attempted cure would be risky and unlikely to succeed; it is unclear why substance abuse should be treated differently. Withholding medical treatment from criminal offenders is not only detrimental to prisoner health and public safety, it is also inconsistent
with retributivism and with approaches to symptom management for other medical disorders. US federal and state authorities should work to ensure that addicts receive a reasonable standard of medical care, including, where appropriate, methadone treatment. We declare no competing interests.
Daniel D’Hotman, Jonathan Pugh, *Thomas Douglas [email protected] Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK (DD’H, JP, TD); and Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia (DD’H) 1
2 3 4
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Kershnar S. A defense of retributivism. Int J Appl Philos 2000; 14: 97–117. Gewirtz P. Methadone maintenance for heroin addicts. New Haven: Yale Law School, 1989. Liu H, Grusky O, Zhu Y, Li X. Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior? Drug Alcohol Depend 2006; 84: 114–21.
The Article by Josiah Rich and colleagues1 impressively shows that methadone continuation has major advantages over forced withdrawal in prisoners, a vulnerable population. It is helpful from a psychiatric standpoint to put this issue on solid ground because it is normally dealt with in moral and emotional terms instead of in terms of scientific evidence. Although prisons differ structurally and in terms of the types of prisoners between countries, these results should also encourage methadone continuation in prisons outside the USA. In this context, I would like to know whether illicit drug use was also monitored during imprisonment, and if so, what the findings were in the different study groups. Another important question is how psychiatric treatment and care was organised in those institutions, especially if psychotherapy was also offered. Substance abuse is a very www.thelancet.com Vol 387 January 16, 2016
Firearms kill more than 30 000 Americans annually. 1 Although federal law requires licensed gun dealers to undertake b ackground checks on people who purchase guns, private sales at gun shows and online are exempt from these checks. Universal background checks for gun purchases could substantially reduce the number of gun-related deaths in the USA.2,3 Despite strong public support for universal background checks (92% of 1446 people polled in one survey),4 Congress has failed to act. Some researchers have argued that this disconnect between public opinion and legislation is attributable to a gap in engagement between supporters and opponents of stronger gun control.5 But could it be that public misperceptions of existing gun control laws also contribute to the absence of public mobilisation for new legislation? To answer this question, we undertook a nationally representative survey through the 2014 Cooperative Congressional Election Study (n=1384). Although the American public supports strong gun control laws, many people erroneously believe that these laws have already been enacted and do not support new legislation. 77% (95% CI 75–79) of Americans favoured universal background checks, yet only 53% (51–56) reported preferring stricter gun control laws. This difference might be attributable to poor awareness of the limitations of existing laws. We found that 41% (38–43) of Americans believed that universal background checks are already required by federal law, whereas 47% (44–50) correctly reported that a federal background check is required only for some gun purchases, and 12% (10–14) believed that no federal background checks are required. Among those people who strongly supported universal background checks, correct information about www.thelancet.com Vol 387 January 16, 2016
existing laws predicted support for stricter gun laws. Whereas 74% (95% CI 69–79) of those who incorrectly believed that the USA has universal background checks supported stricter gun laws, 89% (86–92) of those who knew that some gun sales do not require background checks supported stricter laws. We recorded no such relation among those who did not strongly favour universal background checks. We also identified evidence of an engagement gap: among voters who thought gun laws should be less strict than at present, 71% (95% CI 65–78) said they would never vote for a political candidate who did not share their position on gun control, compared with just 34% (30–37) of those who support stricter gun laws. However, the role of policy misperceptions in this domain is not well studied. Public education about the limits of existing laws could be an important way to mobilise support for new legislation. The survey was funded by the Yale Institution for Social and Policy Studies and the Yale Center for the Study of American Politics. We declare no competing interests.
*Peter M Aronow, Benjamin T Miller [email protected] Department of Political Science (PMA, BTM), Institution for Social and Policy Studies (PMA), and Department of Biostatistics, Yale School of Public Health (PMA), Yale University, New Haven, CT 06520, USA 1
2
3
4
5
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Fatal injury reports, 1999–2013, for national, regional, and states. Jan 22, 2015. http://webappa.cdc.gov/sasweb/ncipc/ datarestriction_inj.html (accessed March 30, 2015). Fleegler EW, Lee LK, Monteaux MC, Hemenway D, Mannix R. Firearm legislation and firearm-related fatalities in the United States. JAMA Intern Med 2013; 173: 732–40. Webster D, Crifasi KC, Vernick JS. Effects of the repeal of Missouri’s handgun purchaser licensing law on homicides. J Urban Health 2014; 91: 293–302. Quinnipiac University Polling Institute. July 3, 2014. http://www.quinnipiac.edu/ images/polling/us/us07032014_ulps31.pdf (accessed March 30, 2015). Schuman H, Presser S. Attitude measurement and the gun control paradox. Public Opin Q 1977; 41: 427–38.
Neglected tropical diseases in the Sustainable Development Goals Neglected tropical diseases (NTDs) have been formally recognised as a target for global action towards the Sustainable Development Goals. So can we now get rid of the word neglected? Not yet. Strangely, the NTDs were only a late addition by the Inter-Agency and Expert Group on Sustainable Development Goal Indicators to target 3.3—to “end the epidemics of HIV, tuberculosis, malaria and neglected tropical diseases” by 2030.1 WHO’s proposed NTD indicator— the number of people needing interventions against NTDs—captures a broad set of existing targets with political endorsement by the World Health Assembly, including 11 goals to eradicate or eliminate diseases.2 This indicator counts more than a billion people in low-income, middle-income, and even high-income countries. The proposal of this global NTD indicator shows an aspiration to deliver a package of interventions centred on the poorest and most marginalised populations. I am of course pleased that the Inter-Agency and Expert Group has given a permission to go ahead with our indicator at its second meeting on Oct 26–28, in Bangkok.3 The exclusion of NTDs from the list of indicators for target 3.3 would have been an early setback to the pledge to “leave no one behind”.4 But the inclusion of NTDs is no guarantee of success. The NTD community needs to continue to think outside of the box—the box numbered 3.3. WHO’s Department of Control of Neglected Tropical Diseases has been promoting not only the NTD indicators but also NTD tracers of equity relevant to other Sustainable Development Goal targets. These tracers of equity were proposed as a contribution of the NTD community to monitor equity
Rick Barrentine/Corbis
Policy misperceptions and support for gun control legislation
See Editorial page 200
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
223
Correspondence
and fairness in progress toward other Sustainable Development Goals and targets, including universal health coverage (target 3.8), universal access to safe water (target 6.1), and sanitation (target 6.2).5 These tracers are essential to monitor equity precisely because NTD endemic populations are the least likely to have access to these services at present.6 I do not share the opinion that the main outcome for the inclusion of NTDs within the Sustainable Development Goals would be more money for NTDs.7 Inclusion of NTD indicators and tracers will, on the contrary, help to maximise returns on investment in a broad portfolio of Sustainable Development Goal targets. Inclusion will help to identify the communities that have the greatest need for attainment of these goals: the populations that are the furthest behind in terms of development. I declare no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Dirk Engels [email protected] Department of Control of Neglected Tropical Diseases, World Health Organization, 1211 Geneva 27, Switzerland 1
2
3
4
5
224
Transforming our world: the 2030 agenda for Sustainable Development. United Nations. 2015. http://www.un.org/ga/search/view_doc. asp?symbol=A/70/L.1&Lang=E (accessed Nov 19, 2015). Second meeting of the Inter-Agency and Expert Group–Sustainable Development Goal. Bangkok: Oct 26–28, 2015. http://unstats. un.org/sdgs/meetings/iaeg-sdgs-meeting-02 (accessed Nov 18, 2015). Ban Ki-moon. Opening remarks to the media following the Summit for the Adoption of the Post-2015 Development Agenda. UN Headquarters, Sept 25, 2015. http://www. un.org/apps/news/infocus/sgspeeches/ statments_full.asp?statID=2751#.Vkx2fXYvfIU (accessed Nov 18, 2015). WHO. World Health Assembly (WHA) Resolutions on Neglected Tropical Diseases: 1948–2013. http://www.who.int/neglected_ diseases/mediacentre/resolutions/en (accessed Oct 20, 2015). Methodological note: proposed indicator framework for monitoring SDG targets on drinking water, sanitation, hygiene and wastewater. Geneva: World Health Organization and United Nations Children’s Fund. http://www. wssinfo.org/fileadmin/user_upload/resources/ Statistical-note-on-SDG-targets-for-WASH-andwastewater_WHO-UNICEF_21September2015_ Final.pdf (accessed Oct 6, 2015).
6
7
Water, sanitation, and hygiene for accelerating and sustaining progress on neglected tropical diseases: a global strategy 2015–2020. Geneva: World Health Organization, 2015 http://apps. who.int/iris/bitstream/10665/182735/1/ WHO_FWC_WSH_15.12_eng.pdf?ua=1 (accessed Oct 6, 2015). Horton R. Offline: The “chronic pandemic” that just won’t go away. Lancet 2015; 385: 758.
Methadone for prisoners Research by Josiah Rich and colleagues (July 25, p 350)1 shows that forced methadone withdrawal in prisons is associated with substantial individual and societal costs. These costs might be tolerable if a sound clinical or correctional rationale existed for forced withdrawal, but it does not. Retributivists might argue that criminal offenders should be punished for their wrongdoing, whereas providing methadone treatment rewards it.2 However, incarcerated offenders are already receiving punishment. Requiring prisoners to cease methadone treatment forces them to endure the physical and psychological burdens of opiate withdrawal in addition to those of imprisonment. This amounts to a double punishment and is inconsistent with the core principle of proportionate punishment that governs retributivism. Hardline anti-drug campaigners might argue that we should avoid treatments that seek to mitigate symptoms by replacing one addiction with another. 3 Instead, the goal should be abstinence from all drugs. However, evidence suggests that forced withdrawal rarely produces the long-term cure that such campaigners seek.4 For other medical disorders, clinicians and patients often opt for symptomatic relief when an attempted cure would be risky and unlikely to succeed; it is unclear why substance abuse should be treated differently. Withholding medical treatment from criminal offenders is not only detrimental to prisoner health and public safety, it is also inconsistent
with retributivism and with approaches to symptom management for other medical disorders. US federal and state authorities should work to ensure that addicts receive a reasonable standard of medical care, including, where appropriate, methadone treatment. We declare no competing interests.
Daniel D’Hotman, Jonathan Pugh, *Thomas Douglas [email protected] Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK (DD’H, JP, TD); and Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia (DD’H) 1
2 3 4
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Kershnar S. A defense of retributivism. Int J Appl Philos 2000; 14: 97–117. Gewirtz P. Methadone maintenance for heroin addicts. New Haven: Yale Law School, 1989. Liu H, Grusky O, Zhu Y, Li X. Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior? Drug Alcohol Depend 2006; 84: 114–21.
The Article by Josiah Rich and colleagues1 impressively shows that methadone continuation has major advantages over forced withdrawal in prisoners, a vulnerable population. It is helpful from a psychiatric standpoint to put this issue on solid ground because it is normally dealt with in moral and emotional terms instead of in terms of scientific evidence. Although prisons differ structurally and in terms of the types of prisoners between countries, these results should also encourage methadone continuation in prisons outside the USA. In this context, I would like to know whether illicit drug use was also monitored during imprisonment, and if so, what the findings were in the different study groups. Another important question is how psychiatric treatment and care was organised in those institutions, especially if psychotherapy was also offered. Substance abuse is a very www.thelancet.com Vol 387 January 16, 2016
