Intended for healthcare professionals

Observations Yankee Doodling

How to react to the Orlando massacre?

BMJ 2016; 353 doi: (Published 14 June 2016) Cite this as: BMJ 2016;353:i3322
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
  1. dkamerow{at}

Harm reduction may have something to offer

In the aftermath of the awful killings at an Orlando gay nightclub early on the morning of 12 June, we are numbed and left searching for answers. Who did it? Why? What could have been done to prevent the massacre? How can we protect “soft” targets like nightclubs (and schools, offices, and shops) from future attacks?

This was clearly a hate crime in addition to a terrorist act. Omar Mir Seddique Mateen had contacted other gay nightclubs as he methodically planned his attack. He called police directly from the nightclub to pledge his support to the Islamic State organization (ISIS), known for its antipathy to gay people in particular as well as to Western civilization in general. How can we protect our gay and lesbian friends and family members from such atrocities?

In retrospect, Mateen fits all the terrorist profiles: young, male, US born son of Muslim immigrants, a history of violence, heard to utter racist and homophobic threats, access to guns as a security guard. Starting in 2013 the FBI correctly identified him, followed him up, and opened an investigation—twice. In neither case, though, could the agency confirm that he was linked to terrorists, and the inquiries were closed.

“Self actualized” terrorists

This is a huge problem: the threat of “self actualized” terrorists who respond to calls by ISIS and similar organizations to carry out killings abroad. Law enforcement and intelligence agencies are working overtime to try to find and assess such people. Even when they do, though, they may not find the evidence of terrorist acts or contacts needed to detain them. “False negatives” in such investigations can have huge costs, as we saw in Orlando. Other home grown terrorists escape notice altogether, such as the San Bernardino couple who also pledged allegiance to ISIS and killed 14 county employees at a reception in December. The FBI just needs to be wrong once, and we have another mass murder on our hands.

Everyone agrees that we should redouble efforts to defeat ISIS abroad and detect and prevent ISIS inspired attacks at home. Given the difficulty of both endeavors, though, and the seeming ease with which people can launch mass shootings here in the US, perhaps we should also take a page from the drug treatment world and consider possible harm reduction strategies.

Given our history (and constitution), there is no way the US is going to ban private ownership of handguns and rifles. But what about semi-automatic assault rifles? Mateen, like the perpetrators of many mass shootings in the US, whether terrorist killings or not, used an AR-15 type assault rifle.1 Whether it was fully automatic is not known yet, but all these guns have a semi-automatic mode that allows speedy firing of large numbers of lethal, high velocity bullets in competent hands. It is much more difficult to kill dozens of people with a handgun or rifle than with a semi-automatic assault rifle.

The first tenet of harm reduction is that the alternative is less harmful than the established harm. Handguns and rifles are less harmful than assault rifles in mass killing situations. Perhaps banning assault weapons like the AR-15 and others would decrease the lethality, if not the likelihood, of future mass killings. We had a recent, ineffective ban on assault rifles in the US for 10 years. It expired in 2004. Maybe it is time to try again, banning assault rifles while we await the defeat of ISIS at home and abroad.



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