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, 1980:241- 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 firearms 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 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 mordidity, 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 assertation 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 firearms 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 is 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. REFERENCES ALTMAN, L.K. (1987) "Scandals Point to Weakness in Review Process." New York Times (July 21). ARTZ, F.B. (1980) The Mind of the Middle Ages. Chicago University of Chicago Press. BAKER, S.P. and A.E. WALLER (1989) Childhood Injury: State by State Mortality Facts. Baltimore: Johns Hopkins University School of Public Health. BJS (1989) Criminal Victimization in the United States, 1987. Washington, D.C.: U.S. Department of Justice. BLACKMAN, P.H. (1989) "Correspondence." JAMA (Journal of the American Medical Association) 261 (May 12): 2637-2638. BLACKMAN, P.H. (1990) "Correspondence." NEJM 323 (July 12):136. BOORSTIN, D.J. (1983) The Discoverers. New York: Random House. BOYD, J.H. (1983) "The Increasing Rate of Suicide by Firearms." NEJM 308 (April 14): 872-874. BROWNING, C.H. (1976) "Handguns and Homicide: A Public Health Problem." JAMA 236 (Nov. 8): 2198-2200. CDC (Centers for Disease Control) (1985a) Suicide Surveillance, 1970-1980. Atlanta (March). CDC (1986a) Youth Suicide in the United States, 1970-1980. Atlanta: CDC. CDC (1986b) Homicide Surveillance: High-Risk Racial and Ethical Groups--Blacks and Hispanics 1970 to 1983. Atlanta. CDC (1987a) "Youth Suicide--United States, 1970-1980." MMWR (Morbidity and Mortality Weekly Report) 36 (Feb. 20): 87-89. CDC (1987b) "Premature Mortality Due to Suicide and Homicide -- United States, 1984." MMWR 36 (Aug. 21): 531-34. CDC (1987c) "Homicide Surveillance: High-Risk Racial and Ethnic Groups--Blacks and Hispanics, 1970-1983." MMWR 38 (Oct. 2): 634-636. CDC (1988a) "Progress Toward Achieving the National 1990 Objectives for Injury Prevention and Control." MMWR 37 (March 11):138-149. CDC (1988b) "Cluster of Suicides and Suicide Attampts -- New Jersey." MMWR 37 (April 15): 213-216. CDC (1988c) "CDC Recommendations for a Community Plan for the Prevention and Containment of Suicides Clusters." MMWR 37 (Aug. 19): Suppl. no. s-6. CDC (1988d) "Premature Mortality Due to Homicides -- United States, 1968-1985." MMWR 35 (Sept. 9): 543-545. CDC (1989a) "Impact of Homicide on Years of Potential Life Lost in Michigan's Black Population." MMWR 38 (Jan. 13): 4-11. CDC (1989b) "Firearms-Associated Homicides Among Family Members, Relatives, or Friends -- Ohio." MMWR 38 (April 21): 253-256. CDC (1989c) "Tree Stand-Related Injuries Among Deer Hunters--Georgia, 1979-1989." JAMA 262 (Nov. 10): 2510, 2512. CITIZENS COMMISSION ON HUMAN RIGHTS INTERNATIONAL (1989) A Summary of the Psychiatric History of Selected Murderers and Mass Murderers. COMMITTE ON TRAUMA RESEARCH et al. (1985) Injury in America: A Continuing Public Health Problem. Washington: National Academy Press. COMMITTEE TO REVIEW THE STATUS AND PROGRESS OF THE INJURY CONTROL PROGRAM AT THE CDC (1988) Injury Control: A Review of the Status and Progress of the Injury Control Program at the Centers for Disease Control. Washington: National Academy Press. CONSUMER REPORTS (1989) "Radon: The Problem No One Wants to Face." Consumer Reports 54(October): 623-25. CONSUMER REPORTS (1990) "Forget About Cholesterol?" Consumer Reports 55(March): 152-57. DAVIDSON, L.E. et al. (1989) "An Epidemiologic Study of Risk Factors in Two Teenage Suicide Clusters." JAMA 262 (Nov. 17): 2687-2692. DUNFORD, F.W. et al. (1990) "The Role of Arrest in Domestic Assault: The Omaha Police Experiment." Criminology 28 (May): 183-206. EDDY, D.M. et al. (1987) "Estimating the Effectiveness of Interventions to Prevent Youth Suicides." Medical Care 25 (Dec.): S57-S65. FACKLER, M.L. (1986) "Ballistic Injury." Annals of Emergency Medicine 15(Dec. 12): 1451-1455. FACKLER, M.L. et al. (1988) "The Wound Profile: Illustration of the Missle-tissue Interaction." Journal of Trauma 28 Suppl. (January): S21-S29. FACKLER, M.L. (1988) "Wound Ballistics: A Review of Common Misconceptions." JAMA 259 (May 13): 2730-2736. FACKLER, M.L. (1989) "Wounding Pattern of Military Rifle Bullets." International Defense Review 1/1989:59-64. FACKLER, M.L. et al. (1990) "Wounding Effects of the AK-47 Rifle Used by Patrick Purdy in the Stockton, California, Schoolyard Shooting of January 17, 1989." American Journal of Forensic Medicine and Pathology 11: 185-189. FBI (1989) Crime in the United States, 1988. Washington, D.C.: GPO. FINGERHUT, L.A. and J.C. KLEINMAN (1989) Firearm Mortality Among Children and Youth. Advance Data #178. NCHS (Nov. 3). FINGERHUT, L.A. and J.C. KLEINMAN (1990) "International and Interstate Comparisons of Homicides Among Young Males." JAMA 263 (June 27): 3292- 3295. FISHBEIN, D.H. (1990) "Biological Perspectives in Criminology." Criminology 28 (Feb.): 27-72. FORSYTH, P. (1985) "Epidemic of Killing." Washington Post/Health (Feb. 20):9-10. GOLDSMITH, M.F. (1989) "Epidemiologists Aim at New Target: Health Risk of Handgun Proliferation." JAMA 261 (Feb. 3): 675-676. GRAITCER, P.L. (1987) "The Development of State and Local Injury Surveillance Systems." Journal of Safety Research 18 (Winter): 191-198. GULAID, J.A. et al. (1988) "Differences in Death Rates Due to Injury Among Blacks and Whites, 1984." MMWR 37 (SS-3): 25-31. HAMILTON, J. (1989) "Medical Journals Can Make You Sick." Washington Post/Health (Oct. 31): 7. HARVARD MEDICAL PRACTICE STUDY (1990) Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York. HINES, W. and J. RANDAL (1989) "Peer Reviewers Debate Policing Medical Journals." Washington Post/Health (May 16): 11. HOTZ, R.L. (1985) "CDC Puts Murder Under the Microscope." Atlanta Journal and Constitution (Jan. 1): A-16 HUDGENS, R.W. (1983) "Editorial: Preventing Suicide." NEJM 308(April 14): 897- 898. INTERPOL (n.d.) International Crime Statistics, 1985-1986. St. Cloud, France. KELLERMANN, A.L. and D.T. REAY (1986) "Protection or Peril?: An Analysis of Firearm-Related Deaths in the Home." NEJM (June 12): 1557-1560. KELLERMANN, A.L. and D.T. Reay (1986b) "Correspondence." NEJM 315 (Dec. 4):1484. KLECK, G. (1987) "Letters to the Editor." American Journal of Public Health 77 (April): 513. KLECK, G. (1988) "Crime Control Through the Private Use of Armed Force." Social Problems 35(February): 1-21. MARZUK, P.M. et al. (1988) "Increased Risk of Suicide in Persons with AIDS." JAMA 259 (March 4): 1333-1337. MAXWELL, S.L., Jr. (1984) "Correspondence." NEJM 310(Jan. 5): 46-47. MERCY, J.A. et al. (1984) "Patterns of Youth Suicide in the United States." Educational Horizons 62 (Summer): 124-127. MERCY, J.A. et al. (1986) "Patterns of Homicide Victimization in the City of Los Angeles, 1970-1979." Bulletin of the New York Academy of Medicine 62 (June): 427-445. MERCY, J.A. and V.N. HOUK (1988) "Firearm Injuries: A Call for Science." NEJM 319(Nov. 10): 1283-1284. MERCY, J.A. and P.W. O'CARROLL (1988) "New Directions in Violence Prediction: The Public Health Arena." Violence and Victims 3: 285-301. MERCY, J.A. and L.E. SALTZMAN (1989) "Fatal Violence Among Spouses in the United States, 1976-85." Americaan Journal of Public Health 79: 595-599. MEREDITH, N. (1984) "The Murder Epidemic." Science 84 5 (Dec.): 42-48. MOORE, T.J. (1990) "Overkill." Washingtonian 25 (August): 64-67, 194-204. MORGAN, E.C. (1990) "Assault Rifle Legislation: Unwise and Unconstitutional." American Journal of Criminal Law 17 (Winter): 143-174. NCIPC (National Committee For Injury Prevention And Control) (1989) Injury Prevention: Meeting the Challenge. American Journal of Preventive Medicine (Supp.). NCHS (National Center For Health Statistics) (1990) Vital Statistics of the United States, 1987. Vol. II: Mortality, Part A. Hyattsville, Md.: U.S. Dept. of Health and Human Services. NKF/NCA (National Kidney Foundation of the National Capitol Area) (1990) "Statistics on Kidney and Kidney-Related Diseases." NKF/NCA News (Fall): 2. O'CARROLL, P.W. (1988) "Homicides Among Black Males 15-24 Years of Age, 1970- 1984." MMWR 37 (SS-1): 53-60. O'CARROLL, P.W. (1989) "Correspondence: CDC's Approach to Firearms Injuries." JAMA 262 (July 21): 348-349. O'CARROLL, P.W. et al. (1989) "Preventing Homicide: An Evaluation of the Effectiveness of a Detroit Gun Ordinance." Paper delivered the annual meetings of the American Society of Criminology, Reno (November). O'CARROLL, P.W. and J.C. SMITH (1988) "Suicide and Homicide," pp. 583-597 in H.M. Wallace et al., eds. Maternal and Child Health Practices, 3rd Edition. Oakland, Calif.: Third Party Publishing. ONWUACHI-SAUNDERS, E.C. et al. (1989) "Firearms-Related Assaults on Los Angeles Roadways." JAMA 262 (Oct. 27): 2262-2264. PHS (Public Health Service) (1979a) Healthy People The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, D.C. PHS (1979b) Healthy People The Surgeon General's Report on Health Promotion and Disease Prevention: Background Papers. Washington, D.C. PHS (1986) Surgeon General's Workshop on Violence and Public Health: Report, 1985. Rockville, Md. PHS (1990) Healthy People 2000, Conference Edition. Washington, D.C. POLLOCK, D.A. et al. (1988) "Deaths Due to Injury in the Home Among Persons Under 15 Years of Age, 1970-1984." MMWR 37 (SS-1): 13-20. POWELL-GRINER, E. (1990) Characteristics of Persons Dying from Cerebrovascular Diseases. NCHS Advance Data No. 180 (Feb. 8). RELMAN, A.S. (1986) "Correspondence." NEJM 315(Dec. 4): 1484-1485. RICE, D.P. et al. (1989) Cost of Injury in the United States: A Report to Congress. Atlanta: CDC. ROSENBERG, M.L. (1984) "Violence as a Public Health Problem: A New Role for CDC and a New Alliance with Educators." Educational Horizons 62 (Summer): 124- 127. ROSENBERG, M.L. and J.A. MERCY (1986) "Homicide: Epidemiologic Analysis at the National Level." Bulletin of the New York Academy of Medicine 62 (June): 376- 399. ROSENBERG, M.L. et al. (1986) "Interpersonal Violence: Homicide and Spouse Abuse," pp. 1399-1426 in J.M. Last, ed. Public Health and Preventive Medicine, 12th Edition. Norwalk, Conn: Appleton-Century-Crofts. ROSENBERG, M.L. et al. (1987) "Violence: Homicide, Assault, and Suicide," pp. 164- 178 in Health Policy Consultation, eds. Closing the Gap. New York: Oxford. SALTZMAN, L.E. et al. (1988) "Suicides Among Persons 15-24 Years of Age, 1970- 1984." MMWR 37 (Feb.): 61-68. SCHOENTHALER, S. et al. (1990) "The Impact of Vitamin-Mineral Supplementation on Intelligence and Brain Function." A paper delivered at the annual meetings of the Academy of Criminal Justice Sciences, Denver (March). SHERMAN, L.W. and R.A. BERK (1984) The Minneapolis Domestic Violence Experiment. Washington, D.C.: Police Foundation. SLOAN, J.H. et al. (1988) "Handgun Regulations, Crime, Assaults, and Homicide: A Tale of Two Cities." NEJM 319(Nov. 10): 1256-1262. SLOAN, J.H. et al. (1990a) "Firearm Regulations and Rates of Suicide: A Comparison of Two Metropolitan Areas." NEJM 322(Feb. 8): 369-373. SLOAN, J.H. et al. (1990b) "Correspondence." NEJM 323 (July 12): 136-137. SMITH, G.S. and H. FAULK (1987) "Intentional Injuries," pp. 143-163 in Health Policy Consultation, eds. Closing the Gap. New York: Oxford. SMITH, J.C. et al. (1985) "Comparision of Suicides Among Anglos and Hispanics in Five Southwestern States." Suicide and Life Threatening Behavior 15 (Spring): 14- 26. SMITH, J.C. et al. (1986) "Suicide and Homicide Among Hispanics in the Southwest." Public Health Reports 101 (May-June): 265-270. SMITH, J.C. et al. (1988) "Comparison of Homicides Among Anglos and Hispanics in Five Southwestern States." Border Health 5:2-15. SNEIZEK, J.E. and T.M. HORIAGON (1989) "Medical-Examiner-Reported Fatal Occupational Injuries, North Carolina, 1978-1984." American Journal of Industrial Medicine 15: 669-678. SOSIN, D.M. et al. (1989) "Head Injury-Associated Deaths in the United States from 1979 to 1986." JAMA 262 (Oct. 27): 2251-2255. STARK, E. (1990) "The Myth of Black Violence." New York Times (July 18): A-21. STEPHENS, J. et al. (1990) "A Biocriminological Survey of Youth in a Georgia Detention Center." Paper delivered at annual meetings of Academy of Criminal Justice Sciences, Denver (March). STOLINSKY, D.C. (1984) "Correspondence." NEJM 310(Jan. 5): 47. U.S. DEPT. OF COMMERCE (1989) Statistical Abstract of the United States. Washington, D.C.: GPO. WOOD, N.P. and J.A. MERCY (1988) "Unintentional Firearm-Related Fatalities, 1970- 1984." MMWR 37 (SS-1): 47-52. WRIGHT, J.D. et al. (1983) Under the Gun. New York: Aldine. WRIGHT, J.D. and P.H. ROSSI (1986) Armed and Considered Dangerous: A Survey of Felons and Their Firearms. New York: Aldine de Gruyter. WRIGHT, J.D. (1988) "Second Thoughts About Gun Control." Public Interest 91 (Spring): 23-39. _ 1The 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. 2FOIA 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. _ 3An 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." 4One could observe, for example, that the "risk factor" most commonly associated with premature death in the United States is the MD. _ 5For 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. _ 6Criminology 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) _ 7A 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. 8One 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 practioner 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." _ 9It 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. _ 10Unfortunately, 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.