A Public Health Epidemic.

April 20, 1999, is forever emblazoned in the memories of Americans. We watched helplessly, through the technology of live television, as more than 2,000 high school students ran for their lives from two of their schoolmates turned assailants. Those of us in Denver that day felt the terror. Those were our neighbors, relatives, and friends who were affected. The full range of emotions - from fear and terror to shock and grief, to rejoicing and joy - enveloped the community and the country as the events unfolded and families learned whether their children, neighbors, classmates, and friends had survived, or were injured, or had been killed.

In the aftermath of this tragedy, the most commonly asked question is "Why?" Why Denver, why Columbine, why such violence in our community? What could have been done to prevent this unprecedented expression of anger and desperation by two teens?

Many groups and individuals have spoken out - through the media, in speeches, during counseling sessions, in schools, at the dinner table, and in many other places - to offer opinions. While there is no simple answer and no quick fix, a compelling theme does emerge: There is an epidemic of anger in our society that drives destructive behavior, including violence against others. The tragic outcomes are preventable, as is the disease itself. In the meantime, this epidemic is as much a risk to the health of communities as any infectious disease, any workplace or environmental exposure, or any other community health risk.

We have a classic disease triangle (agent, host, and environment), and a primary-prevention approach would emphasize eliminating the ability of that triangle to have three legs. In the case of a disease like anger, which might have outcomes like violence, an epidemiologist might ask what variables are involved. Some obvious answers are the absence of a nurturing home environment beginning at birth; domestic abuse and violence; drugs and alcohol; physical and emotional health factors; low self-esteem; mental illness; role modeling by others; the failure of parents, peers, and teachers to recognize and respond to symptoms of the disease; the acceptance of aberrant behavior by society; and the prevalence of images that glorify anger and then condone violence as an acceptable expression of that anger.

In today's society, our response to this outbreak of anger most often takes the form of immediate, short-term fixes. We increase the severity of punishment for violent acts that result from anger (crime), we regulate access to instruments of violence (guns), we educate our children about the evils of drugs and alcohol, we increase the security of our schools to prevent violent acts, and we affix the blame on someone else - or the system - instead of looking in a mirror and seeing ourselves.

This scenario is familiar to public health professionals. How does society respond to other community or public health issues? We look for a cure instead of reducing the risk of contracting the disease. We improve trauma care to address situations in which seat belts and motorcycle helmets have not been used. We provide high-quality intensive care services for unhealthy babies as a substitute for effective prenatal care. We regulate emissions instead of preventing pollution. We set standards for "acceptable" degradation of our environmental resources instead of preserving their current quality.

With the shocking and tragic violence at Columbine High School and in other schools around the country - and in countless similar but less dramatic situations - it seems the message is now clear enough to be heard. The message is that the future health and well-being of our communities begins with the health of our children. The consequences of leaving many more traditional public health problems untreated will appear insignificant if we do not respond to this epidemic of anger that manifests in violence. Our greatest gains in quality and quantity of life have come from prevention, not from responses to outbreaks. Communities expect prevention, but the decision makers and funders have often been reluctant to meet that expectation - except through short-term and often short-sighted reactions that support the status quo. We talk prevention, but we practice treatment. In this case, the disease has already resulted in death. Treatment is likely just to prolong the illness, not to cure it.

There are many questions and few good answers. Columbine High School tragically exemplifies how our communities are at risk. Can a more compelling case be made for preventive intervention? Can children whose physical and emotional health is compromised grow into healthy and productive adults? Public health professionals, among others, have an obligation to recognize and encourage the community response to the epidemic of anger. Maybe those of us in public health have missed the mark in our assessment of important community health issues. We have considered injuries, violence, drugs, alcohol, other lifestyle diseases, and the environment - but have our assessments uncovered all the important factors in that most visible of outcomes we saw at Columbine?

Prevention begins with children and families; children and families are our communities. There is a public health epidemic. Will we recognize it and respond before it is too late?