July 1992 MEMORANDUM FROM: PHB SUBJECT: AMA'S JUNE ASSAULT ON "VIOLENCE" (i.e., FIREARMS) In June, all ten AMA publications focused, to some extent or another, on violence, with special emphasis, especially to the news media, on firearms -- particularly due to the emphasis of the June 10th issue of the Journal of the American Medical Association (JAMA), and the press conference unveiling that issue. Almost every aspect of the magazine (from the cover artwork featuring Munch's "Death of Marat" to the 100-years-ago in JAMA on assaults on medical personnel) focused on violence, including book reviews, letters to the editor, communications, articles, reprints from the CDC, abstracts from other journals, etc., and, of course, editorials. In all, there were roughly 80 items touching on violence of some sort in the ten publications, with guns featured in perhaps 25- 30. Most are relatively innocuous, featuring more data than editorializing; some merely recount other reports (such as the abstract telling how the D.C. gun law has been "effective" from the December 1991 NEJM). What follows, in roughly the order of significance, is a brief statement of the thesis of the various items most apt to be raised, along with some criticism, where warranted, or pointing out the true significance of the findings. Firearms should be treated like motor vehicles, with age limits, registration, and licensing; supporting this position is the decline in motor vehicle deaths reported between 1970 and 1990, as noted in one of the articles reprinted from the CDC in the JAMA.1 Of all the roughly 80 items in the AMA publications, none presented evidence to support the claim that firearms licensing and registration would reduce violence or homicide or gun-related violence. And, for that matter, the CDC reprint regarding motor vehicle deaths cited about seven factors influencing that decline (including redesign of cars, of roads, seat-belt laws, focus on drunk driving, child restraints, etc.), but did not mention registration or licensing -- understandably, since most registration and licensing was enacted between the world wars. And that CDC reprint, emphasizing two atypical states, missed the fact -- demonstrated in the National Safety Council's Accident Facts 1991 -- that the rate of motor vehicle accidental deaths fell less between 1970 and 1990 than the rates of accidental deaths from other public accidents, work accidents, home accidents, and firearm accidents. At the press conference where Koop and Lundberg called for registration and licensing, Lundberg described it as a "first step," and refused to answer a question regarding what subsequent steps would be. In the editorial, reference was made to Koop's having called for a workshop on violence in Leesburg in 1985, but did not mention the fact that the so-called experts there called for a ban on handguns, and restrictions on other arms (including knives). On ABC's "Nightline" show (June 12), where Ted Koppel described the editorial proposal as "the latest entry in the simple answers to complex problems sweepstakes," Koop admitted "If I had my choice, I'd get rid of handguns," but, of the registration/licensing proposal, "You've got to start some place." Ironically, doctors Koop and Lundberg begin their editorial by noting that violence is the lowest of three "fundamental sources of human power" -- the others being money and knowledge -- because "it can only be used to punish" whereas money and knowledge "can be used in an infinite variety of positive as well as negative or manipulative ways." Ignoring the fact that the statement is nonsensical in general, and that if there are only three sources of human power, then violence includes chopping trees and hewing stone to build structures, etc., physicians and surgeons ought to know better. When hit by a car in 1981, my surgeon used a knife to inflict penetrating violence on my knee; later, when he wasn't sure recovery was progressing smoothly, he discussed inflicting blunt trauma in a controlled, but violent, break to the knee. Surgery is violence plus knowledge, not knowledge alone. It is surprising that medical personnel would not know this. Obviously, there are "an infinite variety" of other violent activities performed in medicine. Firearms have surpassed motor vehicles as a "cause" of death in two states, Louisiana and Texas, as demonstrated by changes from 1970-1990. This shows that initiatives to reduce motor vehicle deaths have been working, so something similar should be done with regard to firearms.2 The change was not caused by a rise in firearm-related deaths, but by a more rapid decline in motor vehicle accidents than firearm-related deaths. While the CDC may prefer to credit the motor vehicle decline to public health approaches to motor vehicles, in fact, the rate of decline was less than for other causes of accidental death, including firearms accidents. The comparison is apples and oranges, in this case, accidents with suicides/homicides. In fact, during the 1980s, firearms-related deaths in Texas, even with the inapt comparison, shows a drop for both motor vehicles and firearms -- with Louisiana firearms-related deaths fluctuating -- but so much faster for motor vehicles, that the inapt comparisons show a greater decline for motor vehicles. Family and intimate assaults are 12 times more likely to result in death if a firearm is involved than domestic assaults where a firearm is not involved.3 This article will certainly present a new factoid for the other side, comparable to the six times and the 43 times -- and it has some of the same failings. Unlike those others, however, being written by four of the most active of the CDC- employed anti-gunners, caveats about the limitations of the study are left out. From Kleck's point of view, the key problem is the same as when similar claims were made for homicide/assault overall by Newton & Zimring in the 1960s: It begs the question of whether guns are used because killing is intended or killing results because guns are used. Intent is ignored; all assaults are presumed equally likely to be intended to kill, or not intended to kill -- including pistol whipping. The "scholars" merely assume it doesn't make any difference what intention was; good would come from restricting firearms access anyway -- and, again, there is no consideration of whether firearms use was defensive or aggressive. It involved a study of one atypical jurisdiction (Atlanta/Fulton County) for a period of one year, with a grand total of 23 deaths, or approximately one-tenth of one percent (0.1%) of those which occurred in the U.S. during 1984. It is published at a time when, with the massively reported increase in female firearms ownership, the domestic homicide rate is at, at least, a quarter-century low. There were no data presented involving either the sex of the victim or the determination of the police, prosecutors, or others, as to whether any of the 23 deaths (or any of the 14 involving firearms) were justifiable or self-defense killings. The only domestic violence included in the "study" was that reported to the police. If their Atlanta figures are projected, then there were approximately 50,000 gun-related domestic violence incidents reported to police nationally, and 440,000 total domestic violence incidents reported to police, at a time when the Bureau of Justice Statistics ("Family Violence: Special Report," April 1984) was projecting about a quarter-million gun-related domestic violence incidents reported to police out of a total of 1.3 million domestic violence incidents reported to police; and the BJS was reporting a total of 2.3 million domestic violence incidents (including those respondents said were not reported to police). Both the BJS and JAMA (June 17th) assume that many domestic violence incidents aren't reported to either police or the victimization surveys, putting the overall estimate of annual domestic violence incidents at roughly two to four million domestic assaults on wives, plus others on children, husbands, and other family members. With such a small sample reported to the Atlanta police, absolutely nothing is known about the effects of gun use on domestic violence. Too much is left out -- presumably deliberately, in order to come up with a catchy ratio. The data base is not only unrepresentative of the nation as a whole -- based on comparisons to National Crime Survey (NCS/victimization surveys), but the authors knew their sample was unrepresentative, noting that the NCS often shows weapons often used in other than ordinary ways or not used to injure without firing. "For example, an offender with a firearm may push, hit, or kick the victim. However, in all but two incidents in this study, the injuries sustained were those expected from the types of weapons involved...." The authors call for a variety of means of possibly changing the situation, including reducing access to firearms and reducing the lethality of firearms. They also recommend evaluating the possibility of reducing such assaults through "primary prevention." It is estimated that 2-4 million women are phsically abused each year; domestic violence may touch one-fourth of all American families.4 Since the 2-4 million leaves out physically and sexually abused children, this editorial summary of various studies emphasizes how much was left out in the JAMA study by the CDC.3 "Murder-suicide occupies a distinct epidemiological domain that overlaps with suicide, domestic homicide, and mass murder....The annual incidence of these events is relatively constant across industrialized nations and has not significantly changed over several decades."5 Although one expects JAMA to miss the significance of this article, the key is obviously that there is no particular difference in one type of domestic homicide regardless of a country's traditions of firearms use or violence, gun laws, gun availability, or much anything else. Rhetorically, domestic murder-suicides may spur calls for "gun control," but this study suggests the phenomenon is relatively constant and unrelated to firearms. There is a large and increasing problem of inner-city teenage black males killing one another with firearms. Firearms explain the difference between core city, suburban, and rural differences in homicide rates overall and among the races. Some metropolitan counties are seeing the situation get dramatically worse and others are not.6,7 The authors (the primary author has privately admitted favoring a ban on the private possession of handguns) wish to point out the problem not of homicide but of firearms-related homicide by emphasizing gun-related homicide. One article distinguishes the various counties by four types of metropolitan (core, fringe, medium, and small) vs. non-metropolitan, noting firearm- and non- firearm-related homicide rates for teenagers (defined as 15-19 year olds) by race and sex. The authors' point is that the differences among firearm-related homicide rates are greater than among non-firearm-related homicide rates, especially among males, but also between females, by race. The key differences, however, are (a) black rates are tremendously higher than white rates for firearm-related homicide. For core metropolitan counties, the black firearm-related homicide rate was 144 per 100,000, compared to 21.5 for whites (which probably means roughly half that, in the 10-12 range, for non- Hispanic whites). And (b) the less core big-city, the lower the firearm-related homicide rate for all. In small metropolitan counties, the black rate is two-thirds lower than core, and in non-metropolitan counties, the black teenage male firearm-related homicide rate is 90% lower than in the core counties. For whites, the drops are still there, but less dramatic. And for non-firearm-related homicide, for all groups, the differences between the races and sexes, and the drops with less urbanization are there but less dramatically. In the oral presentation, emphasis was made by the primary author and Lundberg that the data showed that homicide had moved to the suburbs. One black reporter, in follow-up questioning, wondered if the fact that homicide was now affecting whites in addition to blacks was the reason JAMA was suddenly concerned. (Interestingly, if irrelevantly, the primary author was once robbed at gunpoint, I believe, by a black teenage male.) The second study notes dramatic differences in the firearm-related homicide rates among black teenagers in different metropolitan counties between the early/mid-1980s and the late 1980s, but that some counties suffered more glaringly than others, and some were relatively low or relatively high throughout the 1980s. The authors conclude that one must look at differences between the counties to try to determine why some had greater problems than others and what lessons can be learned about those overall lower or higher and those with better or worse trends. The authors are correct. However, a glance at the counties named suggests no apparent connection between gun laws or gun availability and either the rates or the trends in black teen firearm-related killings. And, of course, regardless of the county involved, firearms ownership did not rise dramatically from the early or mid-'80s to the end of that decade. The percentage of households with firearms remained essentially unchanged, and the increase in the number of firearms was rather less than the increase during the decade before, during the latter part of which time, of course, the decline in homicide began (as noted in the second study). The authors ignore what would be obvious to anyone concerned about whether gun ownership/availability is a problem or not: gun ownership levels are generally higher the less core metropolitan a county is, and gun ownership levels are generally higher among whites than among blacks. (Kleck, Point Blank, 1991, chapter 2.) Aside from the offensive emphasis on firearms rather than homicide, the proper point of the two articles is that there is a serious and worsening problem for black teenage males -- who are both the offenders and the victims of these homicides. As the saying goes, the great killer of black teenage males is black teenage males. What the authors ignore, by emphasizing firearms, are the social problems which cause these differences. Similarly, the authors ignore looking at the various metropolitan counties to see which ones had different types of restrictive gun laws during the period study. A quick glance would indicate zero relationship between widespread firearms availability or lenient/restrictive gun laws and any of the rates or trends. Similarly, the authors ignore the fact that for all counties studied, the law generally already proscribes acquisition and sharply restricts possession of handguns, or even long guns. These articles, with nice graphics, have been among the most popular in the news media. But they tell nothing except that going after guns is to deliberately avoid the issue. And it fits in nicely with the CDC approach of sloughing over ethnic differences in order to focus on the harm they associate with firearms. The CDC has proven that violence is a public health problem, and cannot escape looking at the role of firearms (noticing also ethnic variations), and is developing a multi-faceted approach toward improving data collection and reducing the amount of violence.8 This is the official CDC editorial, indicating the CDC's view that it has proven violence to be a public health problem, by constant repetition of the statement that it is a public health problem, and that public health provides approaches to reduce that problem, through careful analysis. More importantly, the CDC gives the line more and more to be seen in the "gun control" debate, and clearly among the emphases it likes: "There is no controversy in the area of children having unsupervised access to loaded guns. No one believes that children should have unsupervised access to loaded guns, but few people are doing anything to prevent children from having such access. This, at least, is a place to start." The CDC also imagines that the motor vehicle accidental death decline is their doing: "Just as we were able to save countless lives from motor vehicles without banning cars, we can save many lives from firearm injuries without a total ban on firearms." For the record, since motor vehicle accidents declined slightly less than other accidents, it must be noted that the CDC pretends that, without public health initiatives, instead of their being roughly 45,000 motor vehicle deaths each year, or about 50,000 or so as there were in the past, there would have been 350,000 deaths annually. It might also be noted that motor vehicle deaths are generally accidental and firearm-related deaths generally intentional, and that the public health folks nonetheless like to speak of reducing the problem without addressing the "nut behind the wheel." They pretend that by collecting data in an improved way, solutions will be found. Among the obvious limitations in their data collection is that they have never even thought about collecting data regarding guns without problems. The collection of data on firearm-related deaths must be improved to include information on the gun (type, make, model, caliber, serial number), type of death (homicide, etc.), demographic and other information (drug/alcohol use) on the victim and on the shooter, circumstances of the shooting, and involvement of emergency medical services.9 The public health types have been calling for improved data collection for over a decade. Although it has been noted that doctors and medical examiners are not particularly adept at collecting such data and that medical examiners now infrequently even bother to note whether a firearm is a shotgun, rifle, or handgun, the NRA, in effect, has already endorsed this proposal (Blackman, Criminology's Astrology: The CDC Approach to Public Health Research on Firearms and Violence, 1990, pp. 20-21) and wondered when the public health folks were going to stop talking about it and start doing something. Our wonder continues. Too many spontaneous killings and woundings are probably due to ready access to loaded firearms. Survey research indicates too many firearms are improperly stored, and there is little evidence that education improves the storage habits of gun owners.10 The "study" begins by noting the GAO study on children's accidents and falsely asserting that the GAO determined that 70% of the nation's accidental deaths involve handguns, whereas the GAO merely looked at an admittedly unrepresentative sample in a single urban area with a higher than normal rate of handgun ownership. The authors noted that NRA and NSSF believe firearms should be stored locked and unloaded. The survey analyzed is the much-reported Time/CNN survey by Yankelovich, Clancy & Shulman in 1989. As reported, the survey found that many guns were loaded and/or unlocked, with this especially true of handguns and where guns were owned for protection. Unfortunately, the survey questions were such that no conclusions can actually be drawn. The question on whether it was kept loaded asked whether "it" was kept loaded always, never, or sometimes. "Kept" is unclear. Similarly worthless was the information on whether "education" increased the likelihood the gun would be stored in a manner acceptable to the authors. "Training" in gun use was defined as either taking a class or getting military instruction. Any private training is thus left out of the "trained" group, and militarily trained were included, even though such instruction has little emphasis on storage of firearms so as to minimize access to children. Since neither "kept," "loaded," "locked," or "trained" were properly or even comprehensibly defined, the survey itself is worthless. And the bias of Time -- as part of its call for a ban on the private possession of handguns -- in having the survey conducted cannot be ignored.* The availability of handguns to urban high school students is pervasive and it is not limited to high-risk groups.11 One of the authors of this work (Rivara) is part of the Kellermann et al. group specializing in pretending Vancouver and Seattle are similar with little pretense to objectivity.** The survey was exclusively in Seattle high schools, thus excluding all non-city students, who presumably have greater access to firearms (based on a North Carolina survey often cited with horror as showing widespread male high schooler access to firearms, despite the lack of any problem). The report pretends that access is rather common -- it is similar to the response one would get if one asked adults about whether there was a firearm in the home. That is, what the researchers are learning is that high school students know if there is a firearm in their home, a not terribly shocking or informative result. The authors note, too, that about 6% of the males say they own a handgun, and about 6.6% have carried it to school at some point. (Note: At this point, one is talking about 30 persons in a survey of nearly 1,000, in an unrepresentative urban area.) Although claiming the access is widespread and not limited to high-risk groups, there was a significant relationship between access to handguns and gang membership, drug selling, involvement in criminal violence, and troublemaking at school. Perhaps most importantly, in terms of undoing credibility for the survey, it conflicts with a more extensive CDC survey which found that 4% had carried a gun (not necessarily a handgun) for protection (not necessarily or likely to school) during the preceding 30 days. The Seattle survey would appear not to be representative of the nation's high schoolers. The AMA will continue to monitor and support legislation banning that allegedly serious threat to public health, the "assault weapon."12 Relying largely on Josh Sugarmann and the Cox newspapers, the AMA just recounts the issue, notes the problem of definition, and nonetheless asserts there is a large and growing problem about which something should be done. Sugarmann, of course, suggested that "gun control" advocates should call for bans on "assault weapons" because of the confusion in distinguishing between machine guns and semi-automatic rifles. It was a fairly open case of attempting public-policy making through deception. The AMA's article was written in June 1990 and not updated, so with so-called "assault weapons" a major issue for 3.5 years, only 1.5 years of that period provided data for the authors. A study of gunshot wound trends in D.C.'s Hospital Center indicate a switch toward semi-autos with resulting increase in number and fatal outcomes of woundings.13 A tripling in admissions to the trauma center (noting that most children are treated at Children's Hospital), with costs about $15,000 per gunshot wound victim) suggests to the authors a serious problem in the switch from revolvers to semi-autos, which the authors believe should be restricted. Oddly, the study notes a number of points unfavorable to the other side. For one thing, the authors note that the number of wounds may indicate not the inherent deadliness of firearms, but the increased tendency for death to be the intended consequence of shooting, and they note this is especially tied to drug-related shootings. This conflicts with the CDC study on domestic assaults which pretends intention is irrelevant.3 Second, they note that half of the hospital costs were covered, with 37% of patients uninsured. This figure is substantially higher than the 14% insured in the widely cited San Francisco study which pretended that 'Frisco was representative of the nation as a whole. (This still suggests relatively high un- and underinsurance, but not as high as another article. One thing the fact tells is that persons who are victims of trauma are unrepresentative of the nation as a whole, where roughly 85% of hospital care is covered by insurance.) The increased number of gunshot wounds per patient still fails to indicate some problem with large-capacity magazines. The dramatic rise was to 8% of those injured by gunfire having five or more entrance wounds -- an amount fully capable of being inflicted with an unreloaded revolver, and still a small percentage. With a handgun ban, D.C. not only saw a rise in the number of gunshot wounds (roughly a tripling from 1987 to 1990), but an increase relative to knife wounds, so the ratio went from 1.1 gunshot wound victims for every knife victim to 1.5 gunshot victims for each knife victim. More significantly, in undercutting the spurious suggestion that the D.C. gun law works is the fact that even the pre- cocaine ratio of 1.1 is higher than would normally exist nationally, with knife woundings far exceeding gunshot wounds. (Victimization survey data would suggest somewhat more knife-related incidents, but knives are more likely to be used to injure victims than are firearms.) Gun attacks have become more lethal in D.C., a widely repeated claim. But, nationally, during the 1980s, firearm-related homicides as a percentage of firearm-related assaults plus homicides, have fallen from about 8% to 5%. D.C. is an exception. The restrictive licensing law in the District of Columbia saved about 47 lives per year, with firearm-related deaths down in the city but not in the surrounding areas.14 This issue was the one picked for repeating the nonsense that D.C.'s virtual handgun ban (described as restrictive licensing) was almost immediately followed by declines in homicide and suicide with guns. In fact, the number of homicides had been falling for the 1.5-2 years prior to the effective date of the law, after which the decline ceased. Suburban areas, with steadily increasing population, actually recorded a drop in homicide rates, while the District, with a diminishing population, recorded increases in homicide rates (except for a brief period when the D.C. mandatory penalty for using a gun in a violent or drug- related offense was effective). (The article was refuted by several letters to the editor in the April 23rd issue of the New England Journal of Medicine, which the authors attempted to refute by falsely asserting that Blackman suggested the homicide decline began in January 1974 and and the homicide decline began two years before the law took effect in October 1976, which is not two years after January 1974.) A juvenile suicide sample of 67 may be small, but when one notes virtually identical results from another sample of 27, well, the NRA is wrong. Besides, the Vancouver-Seattle suicide study was not incompetently performed but "elegant." And how can one suggest that gun availability is associated with mental health when our study of a small mentally unhealthy minority is different from society at large.15 Blackman responded to a small-scale suicide study of juveniles in western Pennsylvania, noting that overall gun ownership levels appeared to be lower among the psychiatrically distressed than in the area as a whole, suggesting the possibility that increased gun ownership in general is associated with increased mental health. The authors of the original study could not comprehend looking beyond the psychiatric patients. They noted their small-scale study produced results similar to an even smaller-scale survey and that led to an inevitable conclusion -- although the total sample still remains fewer than 100 suicides in the western half of a large state. And the authors made it clear that twisting data to prove that 2+2=3 is perceived in the medical community as "elegant." Interestingly, the response to the massively edited letter was longer and allowed more citations than the rules allow for actual letters. Trauma care is expensive, due to knife and gunshot wounds, and many trauma centers are going broke, and help is needed. One possibility is to tax firearms to pay for the harm done with knives and guns to un- and underinsured victims.16 Trauma care is expensive, with costs at about $12,000 per patient. (Other figures suggest anything from about $12-18,000 per patient with a serious gunshot wound.) The author hopes that a tax in firearms to pay for the costs will be a nice step since so many are uninsured. In addition to the obvious -- gunshot wounds are generally lower in number than knife wounds and no similar tax is proposed for them; blunt trauma (motor vehicles) are generally more numerous than gunshot wounds and no similar tax is proposed for them -- is the fact of who is paying and who is the "user" for the fee. For the most part, criminals who misuse firearms have not bought the gun and would not pay the tax. The law-abiding, who do buy firearms, would be forced to pay the tax, but the few instances where they are injured or injure someone else, they have adequate medical insurance. The tax would be almost exclusively on those who do no harm to pay for those who would not pay the tax. Guns are basically evil, defended by cowardly men who need guns to feel manly and by the NRA; "killers are 'typical Americans,' 70 percent of their victims are friends or relatives...many people become criminals only after they have misused the weapon." If we had such excess of deaths from typhoid fever as from criminally caused gunshot fatalities, there would be mass hysteria.17 It is astounding to note that one of the diatribes was originally published some 12 years ago by one of the co-authors of the mid-'70s Cuyahoga County studies, with no updating and no greater appreciation of criminological fact versus medical fantasy. Mostly, it is not an effort to be scientific, and its first appearance was not in a medical research journal. In other words, with JAMA rejecting articles by Kates and by Suter because they were largely literature reviews, the Archives of Surgery reprinted what amounts to literature-review like article -- it certainly isn't a research article -- which has never been, as they say, "peer reviewed" or "refereed." The NRA as bogeyman appears throughout: "The progun lobby, financed primarily by arms manufacturers and spearheaded by the NRA, is a major objector to change in statutory approaches to firearms." There is a threat to trauma centers, which are being overcome with the large numbers of victims of violence.18 The key point of the editorial, actually, is that surgeons are reluctant to work in trauma centers. Surgery residents complained that blunt trauma (motor vehicle accidents) required too much non-operative care, and of "the unsavory type of patients encountered with most penetrating trauma injuries" (knife and gunshot wounds). Other surgeons believed treating trauma victims "would have a negative impact on their practice," presumably because those unsavory characters would come to their offices for post-emergency-room care. Not noted is that there is increasing reluctance of surgeons to treat trauma victims since the combination of drug use with lots of blood is an invitation to contamination and exposure to HIV. The significance of these facts is that it all belies the notion that the average victim of gunshot wounds is just an ordinary person, that we are all victims. The victims are largely unsavory persons; some are just poor; many are just unsavory. Again, this lends support to the proposition that victims of violence are frequently not innocent bystanders but are involved in lives of violence. A journalist might be able to offer some insights into trauma care and the problems emergency-room personnel, and those who pay for medical care, face.19 A lot of the problem with trauma care and emergency rooms is that the same people come in again and again, viewing personal injury as a risk of their occupation as a drug user or trafficker, according to Baltimore Sun reporter David Simon. This is what is running the costs up. "...[I]t is safe to estimate that about seven of every 10 assault victims who arrive at the Baltimore hospital are in some way culpable in the violence that has incapacitated them." "One detective I followed mustered enough cynicism to ... at trauma units: "'You hook up a police computer at the admitting station...[A]nd if a guy comes in with gunshot wounds, you run his sheet and see what kind of priors he has. Then you run him through the hospital computer and see how many times he's been treated there. If you have three confirmed drug-related episodes, you kick his ass out the emergency room door. I'm serious. Let him bleed to death.'" At least, the journalist suggests, make sure those paying for medical care know why their hospital bills are so large, to pay for recidivism drug abusers and criminals. The main flaw is that recidivism, while a serious matter, may not be so great as Mr. Simon perceives. Recidivists account for 6.4% of trauma service at one urban trauma center, with recidivists averaging only 8 months between episodes of injury and, where the outcome is eventually fatal, 19 months between initial injury and death.20 Recidivists were apt to be younger, male, and victims of penetration (knife, gun) rather than blunt trauma; fatalities were even more apt to result from penetration (80%). The figure is relatively low, but other studies have found recurrence of needed treatment to reach rates of 44% and 33%. Guns and drugs are combining to threaten to make the public health problem of violence into an epidemic, especially among the young.21,22,23 Blame is placed on the switch to 9mm. pistols with large capacities, on young persons who have no respect for life, and on drugs. One problem with the "epidemic" idea is that, overall, firearm-related violence decreased in the 1980s. The primary exception is among the age group least capable of lawfully acquiring or owning a handgun. Fulginiti, of the American Journal of Diseases of Children, praised a Rochester medical association attack on guns, an attack noted (the editorial fails to mention) for using false data to support an anti-gun position. It is certainly interesting that the alleged epidemic has occurred during the time when the public health profession was saving us all from violence, since their pretense of a public-health problem which they would solve began about a dozen years ago. Their effectiveness, by their own propaganda, would appear to be minimal: They haven't improved data collection, and they perceive the problem they are to solve as getting progressively worse. The CDC's Mason noted that even the NRA supports gun safety, suggesting some areas of cooperation. We should learn from prohibition and take the profit out of drugs and treating drug abuse as a disease rather than a crime. Gun availability is another problem.24 The mayor of Baltimore attacks criminalization of drugs, preferring the criminalization of guns. Although his article was part of the press packet for the JAMA press conference, JAMA's Lundberg refused to express his views on decriminalization. The AMA is to be praised for focusing such a series of articles on violence.25 Even though there is nothing anti-gun in the article, the general endorsement of the hideously anti-gun approach of JAMA and the AMA is disquieting, and indicative of a support for wasting taxpayer dollars attacking firearms freedom. There are about 140,000 gunshot injuries in the U.S. annually, and something has to be done about it.26 This abstract from an article in the American Journal of Epidemiology looks at the high point of gun-related violence in the U.S. to posit some 140,000 firearm injuries, and issuing various policy recommendations. There have been at least two estimates of injuries in the 60-70,000 range, with the suggestion that 140,000 would include very minor injuries treated in physicians' offices with no emergency-room or hospital treatment. The fact that their data suggest that 0% of accidental injuries are fatal indicates some unrepresentativeness in the sample. "[I]t is useful to point out that nearly everything that leads to gun-related violence among youths is already against the law. What is needed are not new and more stringent gun laws but rather a concerted effort to rebuild the social structure of inner cities."27 This marks the initial release of the latest study -- of incarcerated and non- incarcerated inner-city youths -- by James D. Wright and his colleagues, now of Tulane. They find that violence isn't generated by the schools, but brought there; that little of the violence is random, but most victimization involves persons who take generally unlawful risks, etc. The fact that much of the danger students face occurs outside of school supports the Kleck analysis of the CDC survey of high-school students carrying for protection, that most of the carrying is not going to be at school but at times when they are more needful of protection, which is most likely outside the school setting. "Our findings point away from intervention at the individual level and toward changes in the larger familial, communal, and social situation of those most involved in gun-related violence....Structurally, we are experiencing the development of an inner-city underclass unlike any in our past. In a shrinking industrial economy, we are witnessing the disintegration of the traditional family, increasing poverty and homelessness, diminishing health, and deteriorating educational institutions. The desperation of this situation is enhanced by the apparent enormity of the drug problem and the ready availability of firearms to all. Given all this, perhaps the surprising result is not that there is so much violence in the inner city, but that there is so little." It's not a real polyannaish article. Contrary to expectations, a study in LA suggests that gang-motivated homicides were less likely than other homicides to involve narcotics and narcotics-related homicides were less likely to involve gangs.28 Every so often, the CDC does something which does not particularly offend, although the period studied preceded the worst of the "crack cocaine" problem nationally. Clearly, neurologists should support effective gun control legislation or a handgun ban to reduce violence.29,30 It is curious that these two articles each endorse highly restrictive gun laws. The shorter one, after all, calling for a handgun ban, also comments that restrictive gun laws do not appear to have worked at all, and that smoking has been reduced more by education than by legislation, and the gist of his editorial is for educational approaches toward reducing violence. And the longer one is generally a serious look at neurological causes of violence, with some historical comments on how dramatic increases in violence cannot be explained neurologically, since biological changes are not like that, and goes on to blame such increases, historically, on the loosening of cultural corsets: "Then, as now, the escalation of violence was accompanied by an erosion of personal integrity, widespread dehumanization, a contempt for life, material greed, corruption in high places, sexual promiscuity, and increased recourse to drugs and alcohol." And like biological changes, gun ownership levels have not gone up. Differences in suicide rates are largely explainable by differences in accessibility to lethal methods of injury, so reducing accessibility to special lethal means is important.31 Unfortunately, the study dealt exclusively with the New York City area, and the authors assumed absolutely equal (ready access to all residents) or relatively equal access (some restrictions, but applied equally regardless of borough) for most methods of suicide, including firearms. They assumed that guns were restricted but equally available for Manhattan, the Bronx, Queens, Staten Island, and Brooklyn. They may or may not be right. At any rate, their conclusions were based on unequal availability being assumed for high structures from which to jump, poisoning by prescription agents, motor vehicle exhaust gas, lying before commuter trains, and lying on subway tracks. If anyone attempts to use this article to support restricting firearms access, it might simply be noted that the authors did not test for firearms as something with different access, and their supposed equally accessible items were placed by assumption, not by scientific measurement. "Societal restrictions on access to weapons such as knives and firearms may reduce eye injuries somewhat, although our data indicate that fists and other readily available objects are commonly used in the nonfatal assaults that result in eye injuries."32 The authors of the single effort in the Archives of Ophthalmology to come up with an anti-gun message knew they were pushing it a bit. Their data indicated an average of 14 eye injuries from assaultive gunshot wounds annually recorded in the National Eye Trauma System registry, and not that many (648 in 7 years) from assaults of all kinds. The registry, of course, missed fatalities. Interestingly, a majority of the gunshot wounds were from buckshot (57%) rather than bullets. REFERENCES 1. Koop CE, Lundberg GD. Violence in America: a public health emergency: time to bite the bullet back. JAMA 1992;267:3075-3076. 2. CDC (reprint from Morbidity and Mortality Weekly Report[MMWR]). Firearm-related deaths -- Louisiana and Texas, 1970-1990. JAMA 1992;267:3008-3009. 3. Saltzman LE, Mercy JA, O'Carroll PW, Rosenberg ML, Rhodes PH. Weapon involvement and injury outcomes in family and intimate assaults. JAMA 1992;267:3043-3047. 4. Novello AC, Rosenberg M, Saltzman L, Shosky J. From the Surgeon General, US Public Health Service: a medical response to domestic violence. JAMA 1992;267:3132. 5. Marzuk PM, Tardiff K, Hirsch CS. The epidemiology of murder-suicide. JAMA 1992;267:3179-3183. 6. Fingerhut LA, Ingram DD, Feldman JJ. Firearm and nonfirearm homicide among persons 15 through 19 years of age: differences by level of urbanization, United States, 1979 through 1989. 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From the assistant secretary for health, US Public Health Service: reducing youth violence -- the physician's role. JAMA 1992;267:3003. 23. Fulginiti VA. Editorial: violence and children in the United States. AJDC 1992;146:671-672. 24. Schmoke KL. A public health solution to violent crime. Arch Otolaryngol Head Neck Surg 1992;118:575-576. 25. Novello AC. From the Surgeon General, US Public Health Service: a medical response to violence. JAMA 1992;267:3007. 26. Abstract of RK Lee et al. Incidence rates of firearm injuries in Galveston, Texas, 1979- 1981. JAMA 1992;267:3021. 27. Sheley JF, McGee ZT, Wright JD. Gun-related violence in and around inner-city schools. AJDC 1992;146:677-682. 28. Meehan PJ, O'Carroll PW. Gangs, drugs, and homicide in Los Angeles. AJDC 1992;146:683-687. 29. Elliott FA. Violence: the neurologic contribution: an overview. Arch Neurol 1992;49:595-603. 30. Menken M. Grappling with the enigma of violence: an educational approach. Arch Neurol 1992;49:592-594. 31. Marzuk PM, Leon AC, Tardiff K, et al. The effect of access to lethal methods of injury on suicide rates. Arch Gen Psychiatry 1992;49:451-458. 32. Dannenberg AL, Parver LM, Fowler CJ. Penetrating eye injuries related to assault: the Natonal Eye Trauma System Registry. Arch Ophthalmol 1992;110:849-852. *The bias of the authors is indicated in the way they approach the conclusion: "J. Warren Cassidy, formerly executive vice-president of the National Rifle Association, wrote that gun owners in America are 'safe, sane and courteous in their use of guns.' The large number of gun-related assaults, homicides, suicides, and accidental shootings raises questions about this assertion." **As further indication of bias, the authors graciously thank admitted handgun-ban advocates Wintemute and KK Christoffel, as well as Kellermann, for their review and critique of the article.