From: dickbash@combatarms.com (Dickbash)
Subject: Criminology's Astrology article
Date: Thu,  3 Aug 1995 09:56:34 GMT
To: chan@shell.portal.com


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                            dickbash@combatarms.com
                                August 3, 1995


                           CRIMINOLOGY'S ASTROLOGY: 
      The CDC Approach to Public Health Research on Firearms and Violence
                                      by
                            Paul H. Blackman, Ph.D.
                       Institute for Legislative Action
                          National Rifle Association

                                     1990

               A paper presented at the annual meetings of
               the American Society of Criminology
               Baltimore, Maryland, November 7-10


          Both astronomy and astrology are concerned with precise
     descriptions of the course and relationships between the stars
     and planets, with both interested in predicting the changing
     positions of the heavenly planets, and both able to assist in
     navigation due to their concerns for accuracy (Boorstin, 1983:
     14-21, 264). In addition, astrology was seen as a way of
     understanding what happens to people, with the body but not the
     soul influenced by the movements of the stars and planets
     (Artz, 19 80: 241-43). Similarly, criminology and "public
     health professionals" (Doctors of Medicine and Masters of
     Public Health = MD/MPHs) are concerned with accurate data
     regarding the causes of at least some deaths from external
     causes. Too, astrology, like public health, was an
     interdisciplinary study, part of which was involved with
     medicine (Boorstin, 1983: 305), although some thought
     astrologers "worse quacks than the physicians" (Artz, 1980:
     243) -- a statement with which many criminologists would still
     agree.

          They differ in that astrology attempts to predict the
     future whereas public health professionals want to use their
     data to change the future. They share, however, a
     predisposition to believe that the citation of these figures
     and relationships -- mortality data and trends on the one hand,
     or the movements of the stars and planets on the other -- prove
     something. Unfortunately, at least when the public health
     professionals address the issue of firearms and violence, they
     do not.

          All they produce are numbers and rates, with some
     percentages; these numbers sometimes include trends, with no
     particular meaning. All that count are deaths involving
     firearms. No other factors are measured. Sometimes, they are
     mentioned; and in areas where the MD/MPHs have some knowledge,
     they will give precise lists of the important factors they
     excluded, such as mental illness, alcoholism, etc., with regard
     to suicide. But the assumption is that the numbers alone
     justify the statement of the preconceived belief. Nothing will
     thwart that belief. If the numbers do not fit, then other,
     unknown, factors have been at play keeping the stars from
     acting properly. Description alone is inadequate; the numbers
     must be read, and the assumption is that if MD/MPHs read the
     numbers, society should accept their statements, preconceived
     though they be.

          Science has been identified as that which can be
     disproved. If the facts do not fit in a belief system, on the
     other hand, the facts are altered, or some explanation is
     forthcoming as to why the belief system still holds. So it is
     with astrology, and so it is with MD/MPH studies of firearms
     and violence. No disproof is possible; no proof is necessary.
     The mere statement is believed enough to make firearms and
     violence a public health problem and firearms a risk factor
     subject to epidemiological analysis, with prescription
     forthcoming -- however unrelated to the lists of figures given.

          As astrology and astronomy both sought data on the
     universe, so the public health professionals and criminologists
     both seek data on firearms-related violence. There the
     similarity ends. Criminologists want to understand the nature
     of the problems and to test possible solutions. MD/MPHs want to
     state data and prescribe a predetermined solution, changing
     only as some of the fads discussed by the media change. The
     only sense, thus far, in which MD/MPHs are in any position to
     aid criminologists in their scientific efforts is that they are
     in a better position to improve mortality and morbidity data
     (death and injury) related to firearms and other weapons -- the
     external items in the International Classification of Diseases
     (ICD) -- as collected for the Department of Health and Human
     Services (HHS).

          In a sense, it is unfortunate that the public health
     profession is not better able to assess the problem of violence
     in American society, since, due to a variety of changes during
     the past 13 years, there is considerable federal funding for
     MD/MPH-based research. It is theoretically possible that
     MD/MPHs could learn from social scientists and improve their
     research. There is nothing in the literature to date indicating
     that they care to, and precious little indicating they would be
     capable of it even if they cared to -- any more than
     astrologers could any longer learn from, and in turn assist,
     astronomers. Although the MD/MPHs often talk favorably of
     interdisciplinary study, most uses of criminologists, to date,
     has failed to improve research at all.


     THE U.S. PUBLIC HEALTH SERVICE (PHS) APPROACHES FIREARMS AND
     VIOLENCE

          Although a few MD/MPHs had broached the topic of a public-
     health approach to the study of violence (e.g., Browning,
     1976), and others have done research without federal
     assistance, the real impetus toward a MD/MPH studies began
     between 1977 and 1979 when the Centers for Disease Control
     (CDC) and others worked to prepare the Surgeon General's report
     Healthy People (PHS, 1979a, 1979b), with a series of
     recommendations for improving the health of the American people
     especially setting preliminary 1990 goals, and including
     efforts to reduce violence. The violence especially aimed at
     was suicide among the young, aged 15-24, and homicide among
     young black males (Smith et al., 1986: 269). The goal of
     reducing firearms-related accidents to 1700 by the year 1990
     was achieved by 1982.

          The effort was to be centered in the PHS's Centers for
     Disease Control, where the Center for Health Promotion and
     Education was established in 1981, followed by the Violence
     Epidemiology Branch in 1983, and finally reorganized in 1986
     into the Division of Injury Epidemiology and Control in the
     CDC's Center for Environmental Health. Until 1979, then, the
     CDC was best known for its work on infectious diseases. Since
     then, it has achieved some reputation for its role in
     addressing the problem of violence.

          Interestingly, during the ten years since it began
     expanding its activities beyond the major sphere of infectious
     diseases, the number of deaths annually from infectious and
     parasitic diseases (ICD categories 001-139) has risen 260
     percent, by far the fastest-rising significant cause of death
     -- led by the development of AIDS and a rapid increase in
     septicemia -- and the separately-classified pneumonia and
     influenza have increased over 70 percent. On the other hand,
     the number of accidents has fallen ten percent, the number of
     homicides was the same in 1989 as in 1979, and the suicide rate
     has remained fairly stable. The only exceptions are that in two
     key areas of violence often associated with firearms and of
     greatest concern to the CDC -- suicide among the young, and
     homicide among young black males -- the numbers are up.

          Beginning with conclusions. Although the CDC's goal was to
     bring a scientific approach to the study of violence, the open-
     mindedness and objectivity of its research has always been
     dubious because of the constant conclusions reached prior to
     research. The CDC steadily denies a bias, but the fact remains
     that the spur to its research efforts included calls for
     federal restrictions on firearms, with the suggestion that a
     handgun ban would be appropriate, that reducing handgun
     availability was essential to reduce homicide and suicide, and
     the like. (PHS, 1979b: 18, 64-67, 465; 1979a: 9-21).

          Later efforts, prior to any thorough research, advocated a
     ban on the private possession of handguns (PHS, 1986: 53;
     NCIPC, 1989: 3), and have even given the numbers of thousands
     of lives which would be saved by restricting access to firearms
     (Rosenberg et al., 1987: 174-76; Rosenberg et al., 1986: 1422;
     Rice et al., 1989: 127), and the persons involved in these a
     priori assertions have gone on to do supposedly objective
     research for the CDC, including the first head of the
     epidemiology of violence effort (Mark Rosenberg), one of the
     authors of the study of the Detroit mandatory ordinance (John
     Waller) (O'Carroll et al., 1989), and one of the authors of the
     well- publicized studies comparing homicide and suicide in
     Vancouver and Seattle (Fredrick Rivara) (Sloan, et al., 1988
     and 1990a).

          Other grants, too, seem earned by first getting a
     reputation as an advocate of restrictive gun laws. Kellermann
     and Reay's (1986a) mediocre study of firearms-related deaths in
     King County, Washington -- defended from criticism by lying
     about the results of two national surveys (Kellermann and Reay,
     1986b), and including participation in media debates against
     the National Rifle Association (NRA) -- was followed by grants
     apparently (based on grant materials provided under the Freedom
     of Information Act) totaling just under $750,000 for the
     continuing Vancouver-Seattle comparisons (Sloan et al., 1988
     and 1990a). That figure exceeds by over $50,000 the total
     received by James D. Wright and his associates for two massive
     studies, featuring a number of reports and resulting in two
     full-length books (Wright et al., 1983; Wright and Rossi,
     1986).

          In addition, most media reports on the CDC's study of
     violence give the conclusion that the CDC's efforts are to
     justify restrictive gun laws. This is the case both in popular
     reporting (Hotz, 1985; Forsyth, 1985; Meredith, 1984) and in
     reports to the medical profession itself (Goldsmith, 1989); the
     latter even quoted -- or misquoted -- a CDC researcher as
     saying that "we're going to...systematically build a case that
     owning firearms causes death." The quotation was denied, with
     an exaggerated insistence that the CDC has been careful to
     avoid any bias (O'Carroll, 1989).

          But the bias would be hard to hide. Certainly, it is
     expressed fairly clearly in a number of publications. The CDC
     is in the Department of Health and Human Services, whose leader
     has said he is devoted to reducing the availability of handguns
     in society (Atlanta Journal & Constitution May 1, 1990). The
     first Fingerhut and Kleinman (1989: 6) study on deaths among
     children was open in its goals: "The Public Health Service has
     targeted violence as a priority concern....There is a separate
     objective to reduce the number of handguns in private
     ownership....The data presented in this report underscore these
     concerns." And, while education is a generally approved, if
     inadequate, approach to reducing injury, when it comes to
     firearms, education becomes a possible threat lest "safety
     benefits of such courses are outweighed by their ability to
     promote an interest in firearms, an interest which increases
     the number of fire arms in circulation and the potential for
     both intentional and unintentional injuries." (NCIPC, 1989:
     266) The bias is clear, even if study of the unsupported fear
     is the only recommendation. And, while any number of CDC
     reports have reported on aspects of violence, including trends
     and weapon use by age, race, sex, and the like (CDC, 1986a;
     CDC, 1987a; CDC, 1987b; CDC, 1987c; CDC, 1988d; O'Carroll,
     1988; Davidson et al., 1989), with, at most, no more than a
     call for study of a possible relationship between firearm
     availability and part of the problem of violence (Committee on
     Trauma Research et al., 1985; Wood and Mercy, 1988; CDC 1989b),
     there are others who suggest weapons restrictions would be a
     good idea, preceding any study of the subject (Gulaid et al.,
     1988; Mercy and Saltzman, 1989). Indeed, one of the points
     regularly made by CDC studies is that the issue of whether
     firearms constitute a problem and whether restrictions would be
     effective is still open and in need of research (Saltzman et
     al., 1988: 67).

          The CDC has always been inconsistent regarding it research
     on firearms. On the one hand, there is a clear bias shown in
     advocacy of restrictive gun laws and on who is chosen to do the
     research, and in the impression given to the media reporting on
     their activities.[1] On the other hand, the CDC claims it has
     no anti-gun axe to grind, that it is not doing "gun-control"
     research, and even refused to hire one of the leading
     criminologists studying the gun issue, Alan Lizotte, on the
     grounds they were not interested in studying guns. Lizotte's
     works are generally cautious regarding the potential benefits
     of restrictive gun laws.


     Sensitivity and Secrecy

          The CDC and its grant recipients are sensitive to
     criticism that they have an anti-gun bias or are anything but
     objective scholars trying to "bring a sober, scientific
     approach to determining what effect the accessibility of
     firearms may have on the risk of violent injury." (O'Carroll,
     1989) Whether out of concern about criticism, or due to the
     anti-scientific methods encouraged by the New England Journal
     of Medicine (v.i.), CDC's MD/MPHs are less cooperative, less
     forthcoming, and more sensitive to criticism than are most
     criminologists, who rarely conceal data bases and who present
     their tentative findings with an invitation for criticisms,
     even if mere praise is more desired.

          Such is not the case with the CDC. When their study of
     Detroit's ordinance correctly noted that a law relating to
     carrying of firearms would, if effective, be most apt to affect
     gun-related homicides outside the home, instead of using those
     data in a time- series study to see if there were any changes
     compared to other types of homicides, two surrogate measures
     were used: firearm-related homicides, and outdoor homicides,
     but not the two combined (O'Carroll et al., 1989). Professor
     Raymond Kessler, at the oral presentation of the findings,
     asked about the outdoor gun-related homicide data, and received
     no satisfactory explanation. Under the Freedom of Information
     Act, the NRA asked for the data and was told that the CDC did
     not have the data, even though the paper made it clear the data
     had been collected in such a way that firearm-related outdoor
     homicides could be enumerated (O'Carroll et al., 1989), and
     suggested contacting a different author. Requests to two of the
     other co-authors, John Waller and Colin Loftin, were
     ignored.[2]

          And responses to criticism, particularly by the overfunded
     but underqualified Arthur Kellermann and his associates has
     been less temperate than is the norm among scholars taking
     clear stands on controversial issues. In response to criticism
     from criminologists Gary Kleck and James Wright -- both of whom
     support some restrictive gun laws, and one of whom has a
     position in flux over the years (Wright, 1988) -- quoted in a
     letter by the NRA's Blackman (1990), Kellermann and his
     associates responded that "Kleck's and Wright's long-held views
     on the issue of gun control are also well known, and their
     criticism was predictable." (Sloan et al., 1990b). Curiously,
     an earlier article had cited Wright et al.(1983) to support the
     assertion that "restricting access to handguns could
     substantially reduce our annual rate of homicide." (Sloan et
     al., 1988: 1256) They went on to respond to the NRA's criticism
     by irrelevantly saying the NRA should "return to the Defense
     Department the $4.5 million in annual funding provided to
     firing ranges operated by the National Rifle Association" -- an
     apparent misunderstanding of Defense appropriations, since none
     of it goes to NRA-operated ranges. (Sloan et al., 1990b)

          When one of the criticisms of the initial
     Seattle/Vancouver comparison -- with its conclusion that
     "Canadian-style gun control...is associated with lower rates of
     homicide" (Sloan et al., 1988: 1261) -- was that no effort was
     made to determine how Canadian homicide had changed since
     adopting the law as described in their article (Blackman,
     1989), the authors responded that the "intent of our article
     was not to evaluate the effect of the 1978 Canadian gun law"
     (Sloan et al., 1989) Attorney- criminologist David Kopel, in a
     newspaper column printed in two medium-circulation newspapers,
     interpreted that to mean they "had retracted their conclusions
     about Canadian gun laws."

          Kellermann's response was to complain that "representing
     as fact your claim that my co-authors and I 'retracted' the
     conclusion of a paper published in the most rigorous and
     prestigious medical journal in the world is damaging to our
     reputations as scientists and scholars," and to demand a
     retraction or "I will refer this to my attorney." (Letter from
     A.L. Kellermann to D. Kopel, Aug. 23, 1990) Kellermann's
     reaction is unusual among scholars, especially since, from 1986
     on, he had entered into a controversial field where criticisms
     might be harsh. Curiously, too, he responded with a libel suit
     threat to something clearly labeled as opinion and read by a
     few thousand persons while ignoring Kleck's description of his
     research as "worthless," presented in a "news magazine" report
     over National Public Radio (Dec. 16, 1989), and thus heard by
     thousands more than could have read the "op-ed" piece, with a
     higher percentage of the audience members of the profession in
     which Kellermann may have a reputation.

          The CDC and its associates seem to want both to have a
     bias and to be perceived as objective. It is an awkward
     position, but the only importance, of course, is to the
     validity of the public health approach to the firearms issue
     and the quality of the CDC- conducted and funded research.
     Having an anti-gun bias does not mean CDC's research is doomed
     to inadequacy, but CDC materials should, because of the clear
     anti- gun, pro-control bias, be viewed with the same skepticism
     which would normally be accorded research presented by the NRA
     or by Handgun Control, Inc., or its Center to Prevent Handgun
     Violence. And, unfortunately, while the data in a CDC study are
     probably reliable, secondary-source data cannot, at this time,
     be relied upon.


     THE "PUBLIC HEALTH" APPROACH TO FIREARMS AND VIOLENCE

          The question whether firearms involvement in violence
     should invite the attention of public health professionals --
     MD/MPHs, occasionally also possessing or assisted by a J.D. or
     Ph.D. -- depends upon whether firearms-related violence
     constitutes a serious and preventable medical problem, which
     can be addressed by epidemiological study of risk factors and
     the like.

          If the violence is not preventable, then, while treating
     gunshot wounds is relevant to the practice of medicine, the
     firearms issue is not relevant to "public health" (e.g.,
     Rosenberg, 1984: 126). Largely ignoring the issue of
     prevention, the CDC finds a public health issue based on the
     magnitude of the number of cases, usually by adding together
     four firearms-related codes from the ICD categories of
     externally-inflicted causes of death (E): accidents, suicides,
     homicide and legal interventions (although some MD/MPHs
     subtract legal interventions and war-related deaths), and
     deaths involving firearms where it is undetermined whether the
     shooting was accidental, suicidal, or the willful killing of
     another. By simply and repeatedly asserting that it is a public
     health problem, medical attention is justified as far as
     MD/MPHs are concerned (e.g. CDC 1985a; Rosenberg et al., 1987:
     164; CDC, 1988d; PHS, 1986: 49).

          Not only do CDC favored members of the medical profession
     insist that the number of firearms-related deaths and injuries
     make it a public health issue, by counting only deaths,
     dismissing virtually anything not fatal as not yet subject to
     reliable measurement (Kellermann and Reay, 1986b), firearms
     become more important to medicine than to criminology, since
     there are clearly more firearm-related deaths than firearms-
     related willful homicides. The CDC is not necessarily
     interested only in deaths (mortality), but non-fatal injuries
     (morbidity) are more difficult to measure -- particularly since
     the profession wishes to combine all types of gun-related
     deaths together, and they are apt to be associated with
     different ratios of injury-to-death. Generally, the ratios
     discussed are about five to one for gun related injuries and 90
     to one for injury morbidity to mortality overall (Mercy and
     O'Carroll, 1988: 285-86) although one imaginative effort puts
     the gun ratio of injury to death at 30 to one (NCIPC, 1989: 3).

          By looking exclusively at mortality, and perhaps
     morbidity, as the sole areas of interest, the medical
     profession has but a limited means of evaluating anything
     outside the medical arena -- related to firearms or anything
     else -- which might be related to quality of life. Indeed,
     whereas in most fields of endeavor, "quality of life"
     fluctuates within a relatively narrow sphere, in medicine, that
     can mean a range all the way down to the vegetative state.
     Measuring in terms of injury and death obviously limits
     recognizing non-injurious uses of firearms -- even protective
     or, for that matter, non- injurious criminal uses -- as having
     any meaning or value. Applying that restrictive notion to other
     arenas, it would mean evaluating the musical works of Wagner
     based on the numbers of injuries and deaths which might be
     associated with them. An evaluation, by this medical approach,
     would clearly find that Prohibition was a successful experiment
     since the reduction of deaths from cirrhosis exceeded the
     increase in lives lost to homicide. The narrow perspective of
     the public health profession should produce some skepticism
     regardless of the area of inquiry.[3]


     Treating a Non-Epidemic Epidemiologically.

          Although the departmental secretary over the CDC, Louis
     Sullivan, has said there is an "epidemic" of homicides
     involving black men (Washington Post, Dec. 10, 1989), and the
     CDC has claimed an "epidemic" of teenage and adolescent suicide
     or handgun-related homicide (Rosenberg, 1984: 127; Rice et al.,
     1989: 23), for the most part, such rhetoric is unnecessary to
     an epidemiological study of what is, in reality, not an
     epidemic but an endemic problem of violence particularly
     affecting certain groups within American society.

          The epidemiological approach merely requires massive
     amounts of data, allowing various "risk factors" to be
     determined, which may be associated with a particular
     "disease." The risk factors are simply factors associated with
     an increased incidence of a particular problem, not necessarily
     the cause of the problem. A risk factor is something with a
     higher association than is the norm. With regard to violence,
     the question would be whether firearms are more associated with
     violence, or owned more commonly by victims or perpetrators or
     violence, than is the norm in society -- or in a particular
     portion of society. Although firearms are generally involved in
     about 25% of reported violent crime, and about 10% of National
     Crime Survey crime, firearms are generally found in about half
     of U.S. households and handguns in about 20-25% of households.
     As a risk factor for violence, more data would be needed --
     particularly addressing particular segments in society. As a
     risk factor for gun-related violence, the risk factor need not
     be tested, since it has been defined; guns are tautologically a
     risk factor in gun-related violence -- although the small-scale
     Ohio study of gun-related homicide (Wood and Mercy, 1988) found
     gun ownership levels only slightly higher than the national
     norm.

          Since a risk factor simply means some thing or condition
     more apt to be present than in society as a whole, little is
     shown simply by finding something to be a risk factor.[4] Risk
     factors need not be causes of morbidity or mortality, merely
     associated items or activities. The risk factor need not
     necessarily be dealt with; indeed, attempting to deal with some
     risk factors may mislead and prevent proper medical treatment.
     Symptoms, after all, are risk factors, and, while some symptoms
     should be treated, treating others may mask discovery of the
     underlying ailment and prevent proper treatment. To the extent
     firearms may be a risk factor in some violence, gun laws may
     simply be attempts to mask the symptom without treating the
     actual cause of the violence. Treating the symptom rather than
     the ailment may either be beneficial, harmless, or
     counterproductive. To use a real medical example, to the extent
     hypertension is an indication of another problem, lowering
     blood pressure may create the false impression that the real
     problem has been solved and prevent seeking the true cause and
     attempting to cure it. (Moore, 1990)

          The epidemiological approach would look at various factors
     which might be associated with higher, or lower, incidents of
     particular ailments. Just as epidemiologists might note whether
     scurvy, malaria, or other ailments were associated with
     different diets, insects, living conditions and the like,
     regardless of whether the incidence of such disease was high or
     low, stable or fluctuating, so epidemiologists should look at
     firearms-related morbidity and mortality and look to see what
     related factors there are. Unfortunately, the times when
     MD/MPHs look at firearms, all they see are firearms, even if
     other trends should catch their eyes, and raise their concerns.
     Indeed, this is true even when the spur toward public health
     involvement in violence has already focused on the higher risks
     for suicide among teenagers and young adults and on homicide on
     blacks and Hispanics. (Mercy et al., 1984; Smith et al., 1986;
     Smith et al., 1988; CDC, 1988a) Instead of focusing on those
     serious areas of concern and looking for risk factors, MD/MPHs
     associated with the Department of Health and Human Services
     prefer to focus on the firearms issue even if it means
     belittling what has already been evaluated to be a problem. For
     example, when HHS's Jeffrey Boyd (1983) looked at suicide
     trends, he should have noted increasing suicide among teenagers
     and young adults and shown concern about the cause, since there
     was no overall rise in suicide which could be related to
     firearms availability. Similarly, a truly epidemiological
     approach comparing Seattle, Washington, to Vancouver, British
     Columbia (Sloan et al., 1988) would have shown that the
     homicide rates were dramatically higher among the unstable
     Asian population in Seattle than in the more stable one in
     Vancouver, and highest among the blacks of Seattle. At that
     point, further study might have found other clues to what
     caused there to be higher homicide rates based on such factors
     as poverty, education, nutrition, drugs, alcoholism, or any of
     dozens of factors.

          A similar attempt at international comparisons, of
     homicide among young males (Fingerhut and Kleinman, 1990),
     belittled the ethnic factor CDC is supposed to be concerned
     with by combining Hispanics with non-Hispanic whites,
     exaggerating the overall American homicide rate and disguising
     the problem of a young Hispanic male homicide rate about five
     times that of non-Hispanic whites, and that the young black
     male rate was reversing a previous downward trend and the
     Hispanic rate was increasing steadily. (1988 FBI SHR; CDC,
     1986b)

          The epidemiological approach would be concerned with both
     trends and with factors associated both with higher and lower
     levels of death. The CDC approach to firearms, however, misses
     all of those factors for a number of reasons. First, by often
     combining the types of firearm-related deaths, explanatory
     factors are confused. The different death rates among the
     different ethnic groups are minimized by combining
     traditionally high elderly-white suicide rates with high young-
     black homicide rates. Second, all factors except firearms are
     simply ignored, or presumed comparable in the groups studied --
     either expressly (Sloan et al., 1988) or implicitly. Third, in
     looking at firearms, there is no examination of those not
     "afflicted." CDC would have to look both at the healthy and the
     unhealthy to find the differences between the two. They have
     wholly failed to show the slightest interest in the former.

          It is not enough to consider whether suicides or homicides
     often involve the use of firearms -- although the CDC assertion
     that firearms availability "profoundly affects the suicide
     problem" (NCIPC, 1989: 254-55) would be hard to defend, given
     the normality of the American suicide rate compared to that of
     most of Europe. Are gun-owning households more at risk for
     injury than other households, with other factors controlled
     for? Or, for that matter, is gun ownership -- or handgun
     ownership -- only a risk factor among certain categories of
     persons? In medical studies, after all, not everyone is equally
     at risk from the same substance (salt, for example), nor are
     medications necessarily equally beneficial. What may be
     beneficial for the middle-aged white males used for most
     medical research may prove counterindicated for females with
     the same apparent condition. (Moore, 1990) Gun ownership
     without injury would also have to be studied before one could
     determine firearms were a "risk factor," just as hypertension
     without strokes or heart disease, or salt without hypertension,
     would have to be studied before determining whether
     hypertension was a risk factor for strokes or salt a risk
     factor for hypertension. A small-scale CDC study found gun-
     ownership levels not very different from national levels among
     killers of family and friends who used guns, the study
     excluding, among others, all non-gun homicides. (Wood and
     Mercy, 1988)


     Macro to micro

          The small sample covered in that study undermines any
     serious conclusions, and that is part of the problem with the
     way the CDC is using the epidemiological approach. The MD/MPH
     approach is to claim a public health problem demanding
     epidemiological study based on the large number of firearm-
     related deaths and non-fatal injuries (mortality and
     morbidity). The epidemiological approach requires large data
     bases, not small-scale studies.[5] Their studies, however,
     almost never cover anything but mortality, finding morbidity
     difficult to measure. Even survey research is dismissed as a
     source of larger-scale data (Kellermann and Reay, 1986b).

          Having taken the lower figure of deaths, the studies then
     get even smaller in sample size -- with no such restriction on
     the conclusions. Comparing just two cities, Sloan et al. (1988)
     concluded that "Our analysis of the rates of homicide in these
     two cities suggests that the modest restriction of citizens'
     access to firearms (especially handguns) is associated with
     lower rates of homicide....[A] more restrictive approach to
     handgun control may decrease national homicide rates." When
     challenged on the small sample -- two cities, representing less
     than one-fourth of one percent of the U.S. population, for
     example -- they responded that they were studying a large
     sample, some six million person-years (Sloan et al., 1989:
     1217). One could similarly look at a single kidney and announce
     one was studying millions and millions of nephrons.

          The CDC may benefit criminologists by encouraging better
     collection of morbidity and mortality data, but, to date, too
     many of the studies undermine any "epidemiological" approach by
     avoiding large-scale data bases for rather small ones:
     homicides only involving guns from the home of the killing, and
     family and friends and urban environments; hunting accidents
     involving tree stands (CDC, 1989c); tiny numbers of cluster
     suicides (CDC, 1988b and 1988c); roadway shootings in a single
     city excluding gang-related or preexisting domestic quarrels
     (Onwuachi-Saunders et al., 1989). The results may be
     interesting or suggestive but they are not significant, nor
     epidemiological.

          In theory, of course, the medical profession could improve
     in its epidemiological approach to the issue of firearms and
     violence. There are a number of reasons not to be optimistic
     that such improvements will occur in the foreseeable future.


     LIMITATIONS ON THE CDC APPROACH TO THE PROBLEM OF FIREARMS-
     RELATED VIOLENCE

          One problem with the medical profession is that MD/MPHs
     approaching the gun issue look almost exclusively at works
     appearing in medical journals. Citations outside the public
     health profession are rare, and apt to be erroneously or
     falsely cited when used. The FBI Uniform Crime Reports have
     been cited to support the proposition -- long part of anti-gun
     organizational rhetoric-- that handguns account for only 20% of
     firearms owned but are involved in the majority of accidental
     shootings. (Smith and Faulk, 1987: 157) Three studies cite
     Wright et al. (1983) to support the proposition that the
     availability of handguns increases the homicide rate. (CDC,
     1986b: 7; Sloan et al., 1988: 369; O'Carroll and Smith, 1988:
     595) An anti-gun activists' writings are used as evidence that
     licensing works -- although the state cited, South Carolina,
     does not have licensing. (NCIPC, 1989: 265-66) Since the false
     assertion that John Hinckley's gun cost only $29 comes in anti-
     gun advertisements, that appears to be the basis for another
     CDC "fact." (NCIPC, 1989: 261) And so careless is CDC in its
     statistics that one anti- gun group felt free to cite them as
     supporting the absurd figure that handguns are involved in
     about 3,000 teenage suicides annually (Cool It, Florida! press
     release, Oct. 22, 1990) -- a figure invented by the National
     Coalition to Ban Handguns and the American Association of
     Suicidology and adopted by the American Academy of Pediatrics
     -- some 2 times the firearm figure reported to the National
     Center for Health Statistics.


     Medicine and the Media: the Anti-Scientific Approach of NEJM.

          In addition to citing only one another, medical journals
     rely upon MD/MPHs in reviewing articles for publication. The
     issue of "peer review" and the refereeing of medical articles
     is a controversial one (Altman, 1987; Hamilton, 1989) even when
     the articles relate only to medicine. This is especially true
     of the most prominent medical journal, the one with the best
     relations with the national news media, the New England Journal
     of Medicine (NEJM), whose approach to original articles can
     better be described as anti-scientific, rather than merely
     unscientific. The scientific approach of exposing ideas and
     experiments to the critical judgement and testing of scholars
     is expressly rejected by NEJM, which goes first to the popular
     media and will not even consider an article previewed by
     scientists.

          Whereas criminologists and other social scientists
     generally solicit wide-ranging assistance and criticism before
     going public -- for example, many Criminology articles began as
     American Society of Criminology convention papers-- NEJM
     encourages secrecy prior to press time. Original research which
     has been presented in any form elsewhere is barred from
     consideration. Only the peer-reviewers have a chance to preview
     the research. Medical politics and the "Old Boy Network" affect
     whose articles are printed; MD/MPH reviewers generally are told
     the author(s) of the paper they are peer-reviewing. Peers, of
     course, do not have the data sources used by the authors and
     must rely upon their honesty and accuracy for data collected
     (Hines and Randal, 1989). And reviewers would appear to be
     rather careless even in checking the data available. Other
     readers have found simple arithmetic errors in published
     articles (Stolinsky, 1984; Kleck, 1987), and Kellermann and
     Reay (1986a) cited two publications for the statement that less
     than two percent of homicides were legally justified, neither
     of which gave any such figure.

          NEJM has been forced to back off its claims of how
     wonderfully its peer-review system worked (Hines and Randal,
     1989), in part because of an article praising two drugs to
     suppress premature heartbeats in patients with heart attacks,
     which went on to be responsible for an estimated 1500 deaths.
     NEJM defended itself, saying "I think the publication of even
     studies that turn out to be wrong is valuable to society," and
     blaming "naive, non-critical interpretation" of its studies
     (Hamilton, 1989). If NEJM is careless in its peer-reviewed
     medical studies, the problems are exacerbated when it turns to
     its "special articles" on areas outside the strict parameters
     of biomedicine, where small- scale findings quickly become all
     but definitive as the news media cover medicine, and NEJM
     covers the firearms issue.

          The worst of the publications -- with the best lines to
     the general news media -- NEJM is often discounted by NIH
     researchers and academic physicians for its old-boy network and
     lack of serious controls (confidential communications), yet
     called "rigorous" by such beneficiaries of that network as
     Kellermann. NEJM once made a media splash with a new finding on
     AIDS, based on two subjects. A recent study -- denouncing oat
     bran with such coverage as to have millions of dollars worth of
     impact on the food industry -- was based on studying 20
     nutritionists (Washington Post, Jan. 31, 1990, p. E5).[6]

          The NEJM article studying homicide in Seattle and
     Vancouver was perceived universally as saying that the Canadian
     gun law was instrumental in explaining Vancouver's lower
     homicide rate. Yet, when challenged, since the study did not
     notice if the situation had changed since the gun law took
     effect, the authors insisted that "The intent of our article
     was not to evaluate the effect of the Canadian gun law..."
     (Sloan et al., 1989: 1217). Similarly, when challenged on other
     articles praising a gun law, followed by editorial praise of
     both the study and the law, NEJM's editor misleadingly asserted
     that "Both the article about the law and my editorial on the
     subject described the results as 'preliminary' and were
     appropriately cautious in drawing conclusions" (Relman, 1986).
     It is hard to claim caution when articles and editorials are
     sent to the nation's news media on the Monday before Thursday
     publication, but are immune to professional evaluation until
     after publication.

          The best that can be said for NEJM's approach is that
     their "Special Articles," which "venture into general topics
     like economics and social pathology," may be less carefully
     reviewed than the "Original Articles" on "strictly biomedical
     subjects." If so, NEJM's using its medical credentials to push
     "Special Articles" outside its area of expertise, hoping its
     medical reputation enhances acceptance of its "Special
     Articles," is similar to Nobel-winning physicist William
     Shockley hoping his reputation in that field would enhance the
     acceptability of his views as an amateur geneticist. There is
     no particular reason to grant that favor. It would be more
     appropriate to discount -- as likely to have come from NEJM,
     whether on medical or quasi-medical material -- any study
     receiving widespread coverage in the news media on Wednesday
     evening or Thursday.

          In addition to the general proclivity to attract media
     attention to articles on the firearms issue, NEJM may accompany
     such articles with editorials which, if anything, go beyond the
     article. Boyd (1983) noted one study which distinguished
     handguns from firearms in suicide. As it happens, the study was
     of an urban county (where guns owned are disproportionately
     handguns) in the mid-1970s involving a total of 35 subjects.
     NEJM nonetheless editorialized: "In view of these facts, writes
     Boyd, perhaps restriction of the availability of handguns would
     result in fewer Americans' killing themselves. His data are
     convincing" (Hudgens, 1983). If NEJM thinks the problem is
     "naive, non-critical interpretation" of studies, its editorials
     encourage that problem (Hamilton, 1989). Press releases
     represent an additional way to go well beyond the scope of the
     small studies MD/MPHs specialize in. When the NCHS and CDC
     released a small study on firearms-related deaths among 1-19
     year olds, its press release emphasized the upper limit noted,
     calling them children, and misled the public about starting at
     age one. As a result, the misleading inference was that
     firearms were involved in 11% of the deaths, rather than the
     actual 4% for persons 0-19 (Fingerhut and Kleinman, 1989), and
     1.3% for firearms involvement in the deaths of children under
     the age of 15 (NCHS, 1990). In addition, the HHS press release
     used the study to promote a film on youth violence, even though
     the film itself had almost nothing to do with firearms, but was
     instead a study of the way some persons seriously worked to
     reduce the levels of violence among teenagers in a variety of
     locales---and was perfectly in keeping with the originally
     expressed goals of the Department of Health and Human Services.

          Unfortunately, NEJM and other studies of firearms-related
     topics are not the only ones with broad conclusions from very
     limited studies, even when announced as preliminary and not
     directly related to the topic studied. Most recommendations on
     cholesterol intake and desirable levels for the young and the
     old, for the healthy and unhealthy, for men and for women, are
     based on studies of unhealthy middle-aged males (Consumer
     Reports, 1990). An evaluation of MD/MPH studies of firearms and
     violence begins one wondering which medical research standards
     are not brought into play when doctors address the issue, and
     concludes fearing they have been.


     Misinterpreting and Misunderstanding Data

          Peer reviewers or referees are only as good as the peers
     writing. And there is little indication that MD/MPHs writing
     outside purely medical areas can understand the works of
     criminologists, pollsters, and others. Either that, or they are
     indifferent as to whether their statements are true or false
     when they cite outside their own field. A CDC-sponsored book
     which provided a separate chapter for the firearms issue, after
     six other chapters on violence, justified the separate coverage
     on the grounds that "firearms are ubiquitous in almost every
     category of violence." (NCIPC, 1989: 201) But in three of the
     six categories -- domestic violence, elder abuse, and child
     abuse -- firearms involvement is on the order of 1%; and for
     the fourth, rape, firearms involvement is under 10%. The
     "ubiquity" of firearms for assault is in the 10-22% range,
     depending upon whether police reports or National Crime Survey
     data are used. And, while firearms are used in the final
     category -- suicide -- about 60% of the time if counting only
     successful suicide attempts, their use may fall below 50% if
     the estimated 25% undercount of the actual number of suicides
     is adjusted for (NCIPC, 1989: 252), and to a not quite
     "ubiquitous" 8% if unsuccessful attempts and suicide gestures
     are included.(NCIPC, 1989: 253)

          And Kellermann and Reay (1986b), responding to criticism
     that their data counted only deaths to conclude that firearms
     were less often used for protection than misused, and
     attempting to show that surveys supported their conclusion,
     wrote: "In 1978, both the National Rifle Association and the
     National [sic] Center for the Study and Prevention of Handgun
     Violence sponsored door-to-door surveys. Both included
     questions regarding firearms and violence in the home....Taken
     together, these two polls suggest that guns kept in homes are
     involved in unintentional deaths or injuries at least as often
     as they are fired in self-defense." In fact, the NRA-sponsored
     survey, while it asked about protective uses of firearms, and
     whether the firearm was fired, did not ask about the location
     of the incident, and did not ask any questions about accidents.
     The survey commissioned by the Center did not ask whether
     protective uses of guns involved their being fired, nor where
     accidents occurred, although it did ask where protective
     incidents occurred (the majority occurred outside the home).
     The Center's protective-use questions were asked only of
     persons who owned handguns for protection. The Kellermann and
     Reay conclusion is refuted by Kleck (1988). The controversial
     study was followed by grants to Kellermann and his associates,
     with each of the following two studies less scientific than its
     predecessor (Sloan et al., 1988; Sloan et al., 1990a).

          Unfortunately, the MD/MPHs who study firearms do not seem
     much better at interpreting the mortality data at which they
     should be more expert. And the CDC's Patrick O'Carroll said:
     "Clearly, if three-fourths of homicides are caused by firearms,
     we have to look at their role" (Goldsmith, 1989: 675). In fact,
     of course, firearms have been involved in about 60% of
     homicides during most of the 1980s.


     Ignorance of Laws and Guns; Knowledge of Media Fads.

          If the effort of CDC is to determine which types of
     "intervention" might reduce violence-related injuries -- or
     just gun-related injuries -- some knowledge of what
     interventions -- gun laws -- have been tried and what their
     effects have been is necessary. For the most part, CDC
     researchers assume gun laws would work, but fail to take into
     account which laws already exist; nor do they care if their
     statement of law is accurate. For example, restrictive handgun
     licensing was praised citing a study of the Washington, D.C.,
     ordinance which prospectively banned handguns rather than
     restrictively licensing them; and a South Carolina law which
     allowed immediate over-the-counter handgun sales, but required
     some recordkeeping, was described as a permissive licensing
     system (NCIPC, 1989: 264-66).

          Two prominent CDC-sponsored studies published in NEJM
     (Sloan et al., 1988 and 1990a) attempted to compare American
     and Canadian jurisdictions with different gun laws, presumably
     with an eye toward determining whether the more restrictive gun
     laws in Canada were associated with lower rates of homicide and
     suicide. Both studies misstated somewhat the laws affecting
     Seattle/King County (Washington State and U.S. federal law) and
     Vancouver and its metropolitan area (Canadian national law).
     The most seriously ignored aspect was in the second study, of
     suicide, where age groups were studied and most of the emphasis
     was on the age groups below the age of 25. Although, in
     general, the laws of the U.S. are less restrictive than those
     of Canada, acquisitions of handguns and of long guns are both
     lawful at a younger age in Canada than in the U.S. --18 vs. 21
     for handguns; 16 vs. 18 for rifles and shotguns.

          Perhaps the most serious such flaw occurred in HHS's Boyd
     (1983), since his study is now considered by MD/MPHs reviewing
     the firearms issue as virtually definitive proof that increased
     firearms availability is associated with increased levels of
     suicide and that restrictive gun laws would curb such suicide.
     Boyd's study, however, covered the period from 1953 to 1978,
     and found that firearms involvement was up (particularly among
     young persons). Ignored by Boyd was the fact that the period
     studied included adoption of the most significant federal gun
     legislation ever adopted, the Gun Control Act of 1968
     (Stolinsky, 1984), and the most widespread adoption or
     extension of state and local firearms laws -- especially aimed,
     as Boyd recommended, at handguns -- in American history,
     covering most of the population with some form of restrictions.
     Many of the laws adopted were aimed, among other things, at
     restricting the access of persons under certain ages --
     including parts, at least, of the age group for which Boyd
     found suicide rising, and about which the Department is
     supposed to be most concerned.

          Similarly, Fingerhut and Kleinman (1990) looked at
     variations in the homicide rates, and gun use in homicide,
     across the state lines for half of the states, indicating an
     interest in the possible effectiveness of restrictive firearms
     laws, without noting that the gun laws fluctuated greatly in
     the states involved. They ignored the fact that, in the various
     states -- especially among blacks (a supposed CDC area of
     focus) -- restrictive laws were associated with higher homicide
     rates and lenience and availability with lower rates.
     Similarly, while they suggested firearms laws and availability
     might explain differences internationally, no effort was made
     to determine gun laws or availability in the nations cited.
     And, while noting that the American homicide rates were "four
     to eight times higher than the rates in most other countries,"
     they failed to note that the same was true of robbery, where
     American firearms involvement is about one-third, and rape,
     where guns are used less than 10% of the time. (INTERPOL, n.d.;
     FBI, 1989; BJS, 1989: 64)

          Knowledge of firearms is also lacking, as is clear from
     some of the suggestions on gun and ammunition design changes.
     The most entertaining ignorance was displayed when a CDC
     project praised the effort of Garen Wintemute to ban non-
     existent plastic guns on the grounds, not that they could
     escape detection by security equipment, but that women would
     purchase a variety of the firearms in designer colors to match
     various outfits, and that these guns would look like toys,
     leading to an increase in accidents involving children. Ignored
     in this scenario is the fact that non-plastic fire arms can be
     made in designer colors (see e.g., American Rifleman, October
     1990, p.32-34), or that a woman purchasing handguns for
     protection (a) are not apt to purchase a variety of them to
     match outfits, (b) want a gun which will look frightening to a
     criminal, and (c) have failed to purchase colored guns in the
     past when manufacturers experimented with the idea. While
     crediting Wintemute with congressional legislation banning
     plastic handguns, his arguments apparently influenced no one in
     Congress.

          The non-existent "plastic gun" is just one example of CDC
     following media fads. Another is the issue of semi-automatic
     military-style rifles. With rifle use in homicide on the order
     of four percent (and down from the 1970s), it is hard to
     explain the view that while handguns "account for three-fourths
     of all gun-related homicides,...recent increases in gang
     warfare and the adoption of assault weapons by drug traffickers
     may create different patterns of firearms deaths." (Rice, et
     al., 1989: 23) There is simply no basis for the CDC's
     assertion. (Morgan, 1990: 151-54) The risk to society of
     carelessness in this area is different than with some others,
     since part of the CDC efforts to curtail injury morbidity and
     mortality lies in treatment of such injuries as actually occur.

          Worse than possibly calling for wrongheaded legislation,
     however, is the serious medical threat posed by the MD/MPHs who
     misunderstand wound ballistics; doctors who actually treat
     patients may follow their own and others' rhetorical
     descriptions as emergency-room advice. While military-style
     ammunition -- particularly the AK-47's 7.62x39mm. round --
     tends to make wounds similar to medium-bore handgun wounds and
     less serious than larger rifle ammunition (Fackler et al.,
     1988; Fackler, 1989), if MDs misunderstand wound ballistics,
     their concerns may become a self-fulfilling prophesy by
     emergency-room personnel. If they believe the misinformation,
     they are apt to treat the wounds as if they did more damage,
     and actually aggravate injuries by manhandling organs searching
     for damage which -- aside from the manhandling -- had not
     occurred (Fackler, 1986; Fackler, 1988).[7] "Overstated assault
     rifle effects could...prejudice inexperienced surgeons toward
     the already widespread fallacy that great amounts of tissue
     must be excised when treating wounds made by projectiles
     assumed to be of high velocity, possibly making the treatment
     worse than the wound." (Fackler et al., 1990: 188)

          A final area where the CDC responded to a media fad, with
     a small and misleading study substituted for epidemiological
     research, followed the coverage of freeway shootings in Los
     Angeles. In addition to studying a very minor aspect of injury
     in America, the study was misleadingly presented to meet media
     images. The study concluded that freeway "congestion" was
     related to the shootings -- just as the news media had imagined
     -- even though (a) a majority of the shootings occurred on
     surface roads, for which no data on congestion were available,
     rather than on freeways, and (b) the media-myth-supporting
     conclusion was reached by defining congestion in terms of
     traffic on a particular stretch of freeway rather than by
     whether there was any congestion at the time of the shooting.
     Roughly one-tenth of the firearm-related assaults on the
     roadways involved busy freeways. (Onwuachi-Saunders et al.,
     1989)

          With most childhood injuries not involving firearms (Baker
     and Waller, 1989), and firearms-related injuries to children
     representing a small portion of the problem of firearm-related
     morbidity and mortality, it is unclear whether the recent
     emphasis of the CDC on children (Fingerhut and Kleinman, 1989)
     is also merely a response to the news media's interest in
     finding a new anti-gun target to replace the passe issues of
     unavailable armor-piercing ammunition and non-existent plastic-
     guns.


     Indifference to Medical Care as a Problem Area in Injury
     Intervention

          Perhaps the single leading justification for CDC interest
     in firearms is that firearms-related injuries represent the nth
     leading cause of death, or the second leading cause of injury-
     related death, with injuries the xth leading cause of death;
     and that firearms injuries and/or homicides are the leading
     cause of death among young black males. The high rate of young
     black -- and to a lesser extent young Hispanic -- male
     mortality from intentional injuries is certainly cause of
     public concern. Some of that has to be a social concern.[8]

          Another, relatively minor, concern is the counting
     technique. How firearms or injuries or homicides rank depends
     upon how various ICD categories are combined or separated. An
     imaginative researcher could separate out different causes of
     cancers -- or different types of cancers -- and alter the
     rankings. Food-related cancers may kill thousands more than die
     from firearms-related injuries. (Washington Times, April 16,
     1990, p. F-1) And, while the standard mortality tables list
     kidney-related diseases (nephritis, etc.) somewhat below the
     total of the various types of firearms-related deaths,
     fundraisers --presumably using imaginative techniques in
     combining other ICD categories and subcategories -- triple the
     figure, saying "Kidney disease...claims 80,000 lives each
     year." (NKF/NCA, 1990: 2) And, of course, tobacco and alcohol
     are blamed for hundreds of thousands of lives annually, but
     never included in the rankings as a cause of death or a cause
     of injury-related death; nor has it been suggested that tobacco
     products, presumably causing internal diseases, really are an
     external cause of death.

          More serious is the belittling of poor medical care as a
     cause of death in America. Understandably, health care
     professionals are modest about attributing deaths to medical
     and surgical misadventures and complications. And the formal
     number of such deaths is less than 3,000 (NCHS, 1989). In fact,
     however, there is every reason to believe that medical
     malpractice kills approximately 88,000 Americans receiving
     short term, non-psychiatric hospital care each year, based on a
     New York study. (Harvard Medical Practice Study, 1990: 3 to 5,
     6-21; U.S. Department of Commerce, 1990: 106) That figure for
     deaths from medical negligence vastly understates the total,
     since it excludes all psychiatric maltreatment resulting in
     death, whether by suicide, homicide, or both. The most
     prominent of these mistakes would include murder by Laurie Dann
     and Joseph Wesbecker while on prescription drugs for
     psychiatric problems (Citizens Commission on Human Rights,
     International, 1989), but would also involve ordinary suicides
     by persons under such treatment.

          The figure also excludes malpractice for long-term
     hospital care, and excludes fatal flaws flowing from office
     visits, such as undetected cancers due to physician or
     laboratory error. In addition, since the determination in the
     Harvard study was based on what was considered proper care at
     the time of treatment, medical killings based on following the
     premature recommendations of NEJM or other publications would
     also be excluded. The total number of medically-caused deaths
     almost certainly is competitive with the number of injury-
     related deaths in the United States -- an odd conglomeration of
     motivations and of deaths ranging from bee stings to acts of
     war -- and competes with them and cerebrovascular diseases in
     the close -- an indeterminable due to imprecise, uncertain, and
     insufficiently detailed mortality reports -- contest for third
     worst "killer" after diseases of the heart and cancers.

          And, while the Harvard study did not find race to be a
     risk factor in medical malpractice, there should at least be
     further CDC study of such matters. As has been noted in the
     popular press (Stark, 1990), blacks and whites are similarly
     apt to be the victims of violence, but blacks are far more
     disproportionately victims of fatal outcomes. Certainly the
     victimization surveys show far less distinction between the
     races (BJS, 1989) than do the mortality data. The possibility
     of post-violence intervention or non- intervention should be
     studied more than has been the case until now, as, of course,
     should be the issue of motivation in assaults under different
     circumstances or by members of different groups in society.

          Assumptions vs. Factors: Caveat Lector: While most
     criminologists take into account other factors which might
     influence what is being measured, the public health approach
     generally involves either assuming similarities between
     compared subjects, or, more commonly, warning readers at the
     end what has been ignored and what has been assumed.

          Sometimes the assumptions affect how the research is
     conducted, as when a study of work-place homicides excluded
     those involving people who knew each other, presuming them not
     to be work-place related (Sneizek and Horiagon, 1989), an
     assumption not supported by some publicized killings by
     disgruntled employees or customers; relatively recent examples
     would include a stockbrokerage, a credit union, a press plant,
     and two computer firms. Other times the assumptions affect the
     conclusions. Research on the likely impact of limiting access
     to firearms was based on the assumption that "an intervention
     designed to restrict access to firearms would actually restrict
     access of 50% of potential youth suicides." (Eddy et al., 1987:
     S61-S62)

          A good way to tell what MD/MPHs think is clearly related
     to a topic studied -- homicide, suicide, etc. -- is to look at
     the final caveats, where the reader is warned that the study
     may not apply any other time or place, or may be unreliable for
     a number of reasons. The editorial accompanying Boyd's study of
     suicide (1983) began by noting the role of "depression and
     chronic alcoholism" and "schizophrenia and drug addiction" in
     suicide, before endorsing the Boyd study where those roles were
     ignored and only firearms were considered (Hudgens, 1983).

          The Vancouver/Seattle homicide comparison noted that the
     gun ownership data might not be reliable -- significant for
     something suggesting a relationship between ownership or
     availability and homicide rates -- acknowledged that Seattle
     and Vancouver might be different and thus not comparable, and
     noted that the Seattle area might not be projectible to the
     rest of the United States (Sloan et al., 1988). Their suicide
     study warned that they were ignoring such suicide-related
     factors as alcoholism, mental illness, and unemployment; noted
     that the area might not be comparable to the rest of the United
     States -- especially since gun use in suicide was lower; noted
     that the suicide data might have been flawed; and again noted
     that the gun ownership rates between the Seattle and Vancouver
     metropolitan areas might not have been measured comparably
     (Sloan et al., 1990a). Some of the assumptions made in lieu of
     study are unconvincing. Sloan et al. (1988) simply assumed
     Seattle and Vancouver were similar based on such simplistic
     measures as the rough estimate by police of the clearance rate
     for homicides, the sentence established by law for unlawful
     carrying of firearms, and some aggregate economic data. For
     their follow-up study of suicide (1990a), they switched,
     without explanation, from cities to metropolitan areas, and
     added to the proof of cultural comparability -- previously
     demonstrated mostly by proximity -- that six of the nine most
     popular television shows in one area were among the nine most
     popular in the other as well. Such comparisons could establish
     the cultural similarity of some American rural areas, with high
     school musical and theatrical performances, to big cities with
     symphony orchestras and first-run theaters.

          The CDC said "The paper by Sloan et al....applies
     scientific methods to examine a focus of contention between
     advocates and opponents of stricter regulation of firearms,
     particularly handguns" (Mercy and Houk, 1988). Criminologist
     Gary Kleck wrote: "As a criminologist writing a book on the
     role of firearms in violence, I was disappointed to read the
     recent article on this topic by Dr. John Sloan and his
     colleagues. In a field already plagued by poor research, this
     study used a research design so primitive that it would have
     been regarded as inadequate by criminologists forty years ago,
     and arrived at conclusions which, even under the most generous
     standards of methodological adequacy, cannot be legitimately
     derived from the evidence" (unpublished critique).

          He told National Public Radio's "All Things Considered"
     (Dec. 16, 1989): "The research was worthless. There isn't a
     legitimate gun control expert in the country who regarded it as
     legitimate research. There were only two cities studied, one
     Canadian, one U.S. There are literally thousands of differences
     across cities that could account for violence rates, and these
     authors just arbitrarily seized on gun levels and gun control
     levels as being what caused the difference. It's the sort of
     research that never should have seen the light of day."

          Since one of the issues concerning MD/MPHs is not just
     firearms, but guns owned or acquired for protection, it would
     be interesting to know to what extent the guns whose fatal
     misuse is studied by public health professionals are owned for
     that purpose. Again, the tendency is to simply make the
     assumption, with recommendations made as if the assumption were
     accurate. And Kellermann and Reay (1986a: 1557) concluded that
     "The advisability of keeping firearms in the home for
     protection must be questioned," even though "our files rarely
     identified why the firearm involved had been kept in the home.
     We cannot determine, therefore, whether guns kept for
     protection were more or less hazardous than guns kept for other
     reasons" (1986a: 1559). They assumed protection based on
     surveys showing that three-fourths cite protection as one
     reason for having a gun, although the same surveys cite
     protection as the primary reason only one-quarter of the time.
     The actual reason for initial acquisition or continued
     ownership of firearms involved in injuries remains open to
     research.

          Another odd assumption of the MD/MPH students of the gun
     issue is that firearms restrictions are not aimed at human
     behavior. Boyd (1983) found a "decline in the availability of
     firearms" by law similar to a "decrease in carbon monoxide
     content in domestic gas." And, of course, it is assumed that
     virtually all of the recommendations for restricting access to
     firearms or other potentially lethal weapons will work, even
     though there are many existing restrictions which would allow
     the assumptions to be tested.


     Factors Forgotten and Figures Fudged

          Ironically, the most forgotten factor in CDC studies --
     even though the data are frequently presented -- is ethnic
     variations. It is ironic since one of the espoused goals of the
     CDC in conducting and financing studies to explain, with the
     goal of reducing, the extremely high rate of black-on-black
     homicide and the high rate of Hispanic homicide. Instead, while
     collecting data on the topic (CDC, 1986a, 1986b, 1987a, 1987c,
     and 1988d; Smith et al., 1985; Gulaid et al., 1988; O'Carroll,
     1988; Mercy and Saltzman, 1989), the tendency is to ignore
     these in discussion in favor of focusing on firearms. Sloan et
     al. (1988) found two cities where the non-Hispanic Caucasian
     homicide rates were practically identical, the Oriental rates
     very different (lower for Vancouver's Orientals than for the
     whites; higher in Seattle), and the black homicide rate
     extremely high. They ignored the ethnic difference and focused
     on firearms. (They tried the same approach in the follow-up
     study of suicide, but when ethnic differences were unable to
     show differences in firearms use, they switched to age groups.
     They then concluded, curiously, that gun-restrictions/reduced-
     availability might be able to lower suicide rates in one age
     group without affecting the overall rate. Sloan et al., 1990a.)

          And, while Fingerhut and Kleinman (1990) distinguished
     whites from blacks in their study of youth homicide, Hispanic
     and non-Hispanics are not distinguished, which can be
     misleading when a clearly espoused goal is to reduce Hispanic
     homicide, which first requires data on its extent.{9]

          Other efforts are made to highlight firearms instead of
     other factors and to make things seem worse than the data would
     properly show. Boyd (1983) used a low point of suicide as the
     basis for comparison. (He also added figures incorrectly and
     used a small-scale and old suicide study as evidence that 83%
     of firearm-related suicides involve handguns. None of this was
     caught, apparently, by the NEJM peer reviewers, but only by an
     ordinary reader. Maxwell, 1984.)

          More or less favorable firearms-related death trends are
     fudged a bit with the explanation that things would be a lot
     worse but for improved medical care (Fingerhut and Kleinman,
     1989). CDC researchers like to use only mortality data and then
     to evade its limitations. Undermining the assumption somewhat
     is the fact that injury-deaths from medical/surgical
     complication/misadventure are up, that there are no data
     showing non-fatal firearms-related injuries are up (except an
     absurd claim by the American Academy of Pediatrics showing a
     300% rise among children) from emergency-room surveillance, and
     there appears to be a serious problem with mistreatment of
     gunshot wounds based on myths of ballistics wounding (Fackler,
     1986 and 1988; Fackler et al., 1990).

          A lack of relativity helps as well to fudge the
     significance of numbers -- and percentages -- rhetorically
     without any scientific benefit. When Fingerhut and Kleinman
     (1989) announced that firearms were involved in the deaths of
     11% of children -- carefully excluding 0-1 year olds because
     there were too many deaths (about two-thirds of those occurring
     prior to age 15) and too few involved firearms -- it was
     unclear that the actual numbers of person who die during that
     period is quite low relative to deaths as a whole. When ABC's
     Peter Jennings, relying on MD/MPH data, announced that firearms
     were one of the leading causes of death among persons under 65,
     it was not clear that the age-grouping excluded over 70% of
     American deaths, and still covered under 5% of the remaining
     American deaths.


     CDC CONTRIBUTIONS TO THE STUDY OF FIREARMS AND VIOLENCE

          It is difficult to criticize the methodology of the CDC
     studying the issue of firearms and violence, since, by an
     large, there is none. The studies simply prepare charts on gun-
     related, perhaps compared with non-gun-related, deaths of
     various kinds and among various subgroups in a population.
     There are occasionally breakdowns involving more detailed
     circumstances, but those are largely limited to either a
     particular type of death or shooting or a particular location
     (Sneizek and Horiagon, 1989; O'Carroll, et al., 1989; Onwuachi-
     Saunders et al., 1989; Smith et al., 1986; CDC 1989b; Marzuk et
     al., 1988). Trends over time may be presented, with the
     suggestion -- but no evidence -- that firearms availability was
     increasing. There may be the assertion that a gun law was
     working or would work, but generally with no clear
     understanding of the state of existing law. There may, indeed,
     be mention of a variety of possible risk factors, but with no
     effort to evaluate them (Saltzman et al., 1988).

          The potential for benefits from public health involvement
     in the study of firearms and/or violence is extensive. MD/MPHs,
     for one thing, may be in a better position than traditional
     criminologists to study some of the biological and medical
     influences on criminal or other violent behavior (Stephens et
     al., 1990; Schoenthaler, et al., 1990; Fishbein, 1990),
     including the possible impact of genetic or temporary or
     permanent physiological factors on violence, such as the
     hypothesized "low levels of 5-hydroxyindoleacetic acid" on
     suicide (CDC, 1988a).

          For an epidemiological study of violence, since large
     amounts of data are required, the CDC should be in a better
     position than criminologists to improve the data collection and
     reporting by medical examiners and hospitals (especially
     emergency rooms or via discharge surveys). Such improvements
     are frequently called for (e.g. Committee on Trauma Research,
     1985; Graitcer, 1987; NCIPC, 1989), so that more detailed
     information will be known about injury-related incidents, fatal
     and non-fatal (see page 21 for examples), with more and more
     precise information on weapons, circumstances, and nature and
     extent of injuries.[10] Little, however, has been done to
     implement the proposals. It is unclear, of course, to what
     extent hospitals and medical examiners will be willing or able
     to provide more complete information, but the CDC efforts
     should be made rather than merely called for.

          In addition, greater effort could be made to determine and
     evaluate secondary causes of death. Such data are collected,
     and occasionally used, both in areas of injury -- looking at
     deaths from head injuries and calling for more research on
     potential risks associated with firearms ownership or the
     effectiveness of regulations or other interventions (Sosin et
     al., 1989) -- and non-injury related deaths -- such as the
     other ailments of persons dying from cerebrovascular diseases
     (Powell-Griner, 1990). Since up to 20 associated medical
     conditions may be collected on NCHS tapes, there is certainly
     the opportunity for more extensive analyses. To date, the
     effort has been limited to multiple violence or multiple non-
     violence-related causes; more could be done, particularly with
     regard to suicide, on medical conditions which might encourage
     the violent act, such as Bruno Bettelheim's well publicized
     suicide following a stroke, or the CDC's small-scale (12
     suicides among 3800 New York City patients) look at AIDS
     (Marzuk et al., 1988). Such multiple cause-of-death data might
     involve such homicides as mercy killings, where a non-injury
     disease led to death by injury, or to injury-related deaths
     which, particularly among the elderly, may lead to death from
     natural causes, such as pneumonia attacking an injury-weakened
     body (Washington Post/Health, Oct. 30, 1990, p. 16). Such
     investigations might also point to possible side-effects either
     of ailments or the drugs used to treat them, or suggest
     physiological causes -- or risk factors -- associated with
     violence or victimization.

          Most significantly, were the MD/MPHs properly to use their
     epidemiological approach, the trends toward more firearm-
     related deaths involving persons under the age of 25, in both
     homicides and suicides, and the extremely high rates of
     homicide among black youths, would suggest areas where more
     extensive and realistic efforts should be made to determine the
     nature of such deaths and possible preventive measures. Of
     course, a realistic epidemiological effort would have to take
     into account the fact that firearms ownership, being higher
     among whites and less restrictive among persons over the age of
     21, some other explanatory factors than firearms would have
     been sought. MD/MPHs may be in a position to study some
     possibilities.

          Past performance would not make one hopeful of sudden
     improvements in the criminological research skills of MD/MPHs.
     The 1980s' efforts have seen several criminological conclusions
     reaffirmed, and reported as news; various interesting tables
     with trends on mortality among various segments of society
     produced; and the finding that, if calculated separately for
     whites and blacks, the highest homicide rate is in the West
     (where firearms availability is high in the Mountain states and
     low on the Pacific coast) rather than in the South (CDC, 1986b:
     4). If improved data collection could be added to such efforts,
     then, as astrology was to astronomy, so public health may
     aspire to become to criminology, "a false science that yielded
     various scientific by-products." (Artz, 1980: 167)

          To date, that aspiration may be beyond the grasp of the
     CDC. Although most of their work has been done while
     criminological work has been around as a guide, it has been
     largely ignored, distorted, or misunderstood.

           While some effort by MD/MPHs to interact with the attempt
     to learn from criminologists has been advocated by the CDC, the
     result has been a criminologist praising shoddy public health
     research (Mercy and Houk, 1988) and cooperation with an ill-
     designed study of Detroit's firearms ordinance by persons
     predisposed to claim it was working (O'Carroll et al., 1989;
     PHS, 1986: 53; CDC, 1989a). The few non-CDC criminologists most
     sympathetic to the public health approach came from anti-gun
     backgrounds and are seemingly disappointed in the lack of anti-
     gun findings in criminological research on the issue. They so
     far have accepted public health standards of research rather
     than demanding that public health professionals adopt a
     scientific methodology. Certainly, the CDC's mandate envisions
     working with criminologists (O'Carroll, 1989), but so far the
     CDC has failed to learn from criminologists, and sympathetic
     criminologists have not been insistent on improving public
     health research standards.

          Exemplifying the failings of the CDC and its public health
     approach to the study of firearms and violence are the
     objectives, justifications for the objectives, and proposals
     for meeting the objectives related to violence, particularly
     gun-related violence, in the update for Healthy People (PHS,
     1979a), Healthy People 2000 (PHS, 1990: ch.7). Of about 75
     citations for the chapter on violence, about five are to
     Department of Justice publications, five to studies by
     criminologists on topics not involving firearms, with most of
     the remainder being public health studies by the CDC and other
     MD/MPHs. Regarding firearms, the chapter has two citations to
     criminological research, both by Frank Zimring, the more recent
     one published in 1972.

          The recommendations for specific types of weapons
     restrictions -- such as carrying by high schoolers and storage
     in the home -- are justified by general data on weapons
     involvement in homicide and suicide, references to spontaneous
     shootings, and the like, rather than to topics involving the
     specific areas under discussion. For that matter, the specific
     areas for discussion have not been studied by or for the CDC.
     Among proposals for improving storage, so as to limit immediate
     access to firearms (defined as access to a loaded firearm
     within ten minutes), are irrelevant concepts like mandatory
     penalties for carrying firearms in public, and a waiting period
     (generally perceived as significantly longer than ten minutes).
     No data are cited indicating that carrying is a problem, and
     only one survey is cited regarding its occurrence, so no trends
     can be distinguished. Neither data nor logic are cited
     indicating how firearms are currently stored or indicating how
     laws or other policies regulating storage are to be studied,
     nor how the policies proposed are related to the stated policy
     objectives.

          The public health professionals simply collect and report
     some data, and cite anything that seems interesting at the
     moment as a possible corrective to real or imagined problems.
     Perhaps the fact that the health goals most clearly needed --
     reducing young black and Hispanic homicide and youth suicide --
     are the areas where the CDC has most clearly failed will spur a
     change in the public health approach to the study of violence.



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                                   ENDNOTES

     1.   The least scientific, least original, and most
          vituperative discussion of public health on the
          firearms issue was produced by a "CDC Collaborative"
          (NCIPC, 1989: 295), the Center for Injury Prevention
          which devoted a special issue of the Injury
          Prevention Network Newsletter to the firearms issue
          in Winter 1989-90. The magazine included no original
          research, with its only statistical citations being
          reprints of research of others and/or inaccurate.
          References to the NRA were inaccurate and
          occasionally libellous, as was the critique of the
          works of criminologists Alan Lizotte and David
          Bordua, who were accused of having made a "racist
          assumption" in their work because their demographic
          studies of gun ownership and violence included a
          variable involving blacks. Similar unjustified
          accusations were made of the NRA. Fortunately, while
          the CDC may collaborate with the Center, readership
          of its publication appears negligible.

     2.   FOIA requests which were granted -- requests for
          published material -- often neglected to provide the
          source of publication. The response list also
          included a number of articles by Garen Wintemute as
          having been funded by the CDC, but follow-up resulted
          in a denial of ever granting any funds to the man.

     3.   An additional problem with the public health
          approach, justifying interest -- and legislative and
          other remedies -- for anything which may be
          associated with increased, or reduced, levels of
          morbidity and mortality, is that it invites a sharp
          narrowing of the freedoms most Americans are
          comfortable with, especially the freedom to choose.
          The public health approach says that if it can be
          shown that a particular item or activity is
          associated with an increased risk of morbidity or
          mortality, society has the right to restrict it; if
          it can be shown to be associated with a reduced risk
          of morbidity or mortality, society has the right to
          require it. (In theory, a ban on Wagnerian music
          might be justified. Certainly, comparing only the
          amount of senseless bloodshed associated with each,
          the Star Spangled Banner would be a better national
          anthem then the Marseillaise, using public health
          standards, although musicians might disagree.)
          Clearly, public health professionals are cautious in
          how openly they profess such doctrine, recognizing
          political limits (NCIPC, 1989: 13). In theory,
          however, the approach, noting the costs to society in
          an individual action apparently injuring only the
          individual, justifies actions mandating which foods
          must and must not be consumed. Diet, after all, has
          been mentioned as the "cause" of one-third of cancer
          deaths, which would mean that diet (including ICD
          category E904, starvation, and the few thousand ICD
          deaths from vitamin and other deficiencies and the
          thousands from obesity) is the "cause" of about
          150,000 deaths (NCHS, 1990; Washington Post/Health,
          Jan.30,1990, p.9), and thus competes with
          cerebrovascular diseases for third place after heart
          diseases and other cancers. Sports, obviously, invite
          restriction -- or mandate, for aerobic benefits; and
          all automotive design would be based on injury
          reduction by massive studies of what sorts of
          features limited the incidence and seriousness of
          accidents. A thorough study of clothing might find
          certain garments more associated with injury than
          other based on direct impact to the body (heels in
          shoes, for example) to likelihood to be caught in
          escalators, etc. Big Brother's exercise program could
          certainly prove beneficial. In response to the
          willingness of public health professionals to
          insinuate themselves into all aspects of life, with
          mandates for healthy living, economist-criminologist
          Mark Moore has orally described them as "public
          health fascists."

     4.   One could observe, for example, that the "risk
          factor" most commonly associated with premature death
          in the United States is the MD.

     5.   For much ordinary medical research, small-scale
          studies are appropriate. In theory, medical reports
          in the thousands of poorly regulated medical journals
          are supposed to be a discussion of preliminary,
          interim observations. Doctors are supposed to be
          noticing something based on some of the persons they
          have treated, and to publish their findings to learn
          if others have had similar experiences or if the
          hypothesis based on the initial small sample can be
          readily explained away and a tentative theory
          demolished. Partly for this reason, many studies are
          very modest in their presentation, with warnings,
          understood and heeded, about the limited nature of
          the study.

     6.   Criminology is not immune from leaping from a small
          study to a massive media-hyped conclusion, as Larry
          Sherman demonstrated with the domestic assault issue
          (Sherman and Berk, 1984) -- although the original
          study was at least a genuine experiment with some
          reason to believe the results might be important,
          even if later studies are undermining confidence in
          that (Dunford et al., 1990). One problem shared by
          the public health professionals and by the Police
          Foundation is a tendency for evaluations to be done
          by those committed to the project. Thus, the Police
          Foundation frequently proposes ideas for experiment
          which it believes will work in a jurisdiction and
          also undertakes to evaluate the result of the project
          to which it was committed. Similarly, CDC efforts
          tend to be reviewed publicly by those associated with
          those efforts. (Mercy and Houk, 1988; Committee on
          Trauma Research et al., 1985; Committee to Review the
          Status and Progress of the Injury Control Program at
          the CDC, 1988)

     7.   A Washington, D.C. advertising tabloid, The City
          Paper, Feb. 2, 1990, covering the work of two
          emergency room physicians, graphically described
          poking around and lifting internal organ after
          internal organ in the vain search for serious tissue
          damage in a clean bullet wound -- along with an
          accompanying article with a Fackler warning about the
          dangers of assuming there must be more damage, and
          manhandling organs searching for it.

     8.   One 1990 television pilot involving hospital
          emergency rooms ("The Knife and Gun Club") raised the
          issue with greater objectivity than most CDC
          researchers, when a medical practitioner asked an
          injured young Hispanic male if he knew the leading
          cause of death for young Hispanic males. The answer
          she provided: "Other young Hispanic males."

     9.   It is also not entirely clear, in CDC works
          distinguishing blacks, how others are treated --
          Oriental, Hispanics, Ancient Americans, etc. And,
          while it is clearly technically correct to consider
          Hispanics in general as whites, it is not technically
          correct -- as the CDC is wont to do -- to label non-
          Hispanic whites "Anglos": That wording involves using
          in scientific study an Hispano-American colloquialism
          -- one probably deplored by many non-Anglo-Saxon
          Caucasian Americans.

     10.  Unfortunately, morbidity data associated with
          protective activities appear doomed to unreliability.
          Criminals would not be expected to report injuries
          incurred because of protective measures taken by
          intended victims; both the aggressor and the victim
          are apt to claim to be the victim injured in the
          course of a crime; and it is not always clear in
          mutually aggressive settings who is the offender and
          who the victim.



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