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Gun Smoke

To the Editor:

We are writing in response to Harold Henderson's article about the contemporary epidemic of handgun injury and death ["Guns 'n' Poses," December 16].

We agree with his conclusion that more research is needed to clarify what needs to be done to control this plague. In the years before the control of the polio epidemic, expenditures on polio research stood at $200-300 million dollars a year (in 1993 dollars); about 1 percent as much is spent on researching how to control firearm deaths and injuries, although more than 10 times as many people died from firearms in 1991 than died from polio in 1952 (the peak year for polio). Clearly, more is needed.

However, we feel that Henderson's discussion missed a point that is just as crucial: handguns raise the risk of death by increasing the lethality of whatever else is going on. This is why, as he says, gun injuries are not exactly like motor vehicle injuries. Thus, if someone is interested in committing suicide, the availability of a handgun makes death a more likely outcome; in a community wracked by violence, the ubiquity of handguns causes rampant homicide. This mechanism explains most of the counterarguments Henderson raised to our contention that handguns are the agent in this current plague.

We also disagree with three other aspects of the Henderson article.

First, he uses "violence" and "crime" interchangeably, though they are not synonyms. Most importantly, suicide is not what people think of when they discuss crime, yet it is the most common cause of firearm death in the U.S.; risk is related to handgun ownership in several studies. Further, the reported finding that legal firearm ownership correlates with low crime has no bearing (even if true) on our contention that handgun accessibility (legal or not) correlates with high death by handgun.

Henderson quotes data about criminals to challenge our public health argument, but it doesn't really work. It is logical that people with criminal histories are more likely to be involved in behaviors that are violent; if there are guns handy, this will more often lead to death. Consistent with this, data by Block and Block have recently shown that increasingly deadly handguns lead to increased death even among gang killings. Thus looking at the outcomes for criminals does not contradict our argument. Even if Kleck's extremely high estimates of crimes thwarted by guns are true, such noncrimes must be weighed against actual deaths and injuries: the crime and health measures are not the same!

Second, he states that no one ever said that cigarette smoking is associated with cancer and heart disease deaths because something else led people to smoke and to die of these things. But that is not so: indeed, this is exactly what the tobacco industry did say. This comparison only strengthens the gun-cigarette analogy.

Third, we do not agree that advising people to keep handguns out of reach is the same thing as predicting nuclear war after the 1984 election. When we get beyond this ad hominem argument against medical people like us getting involved in policy matters, it does not seem an illegitimate kind of activity at all.

We believe that all people are vulnerable to handgun death and injury: our bodies are vulnerable to the weapons, because that is how the guns are made; our behavior is vulnerable to our moods, because we are human. We think policy makers and private citizens need to know that. Health care providers at Children's Memorial Hospital have made it our business to learn about this matter because we hate treating children who have been shot, telling parents that their children are dead or paralyzed, and dealing with children whose psyches are scarred by shootings they have experienced or seen. Earlier generations of pediatricians hated treating polio; physicians who treat adults hate dealing with the consequences of smoking. The medicine-policy connection is not new, is not surprising, and is not suspect.

We hope that readers of the Reader will not conclude from Henderson's article that they should acquire handguns, and that they will conclude that they need to press policy makers to fund the research needed for us all to learn how best to save the lives of children . . . and their adults.

Katherine Kaufer Christoffel,

MD, MPH

Chair, HELP Network

Steering Committee

Director, Violent

Injury Prevention Center

Children's Memorial Medical Center

Robert R. Tanz, MD

Chair, HELP Network

Meeting Committee

Associate Director,

Violent Injury Prevention Center

Children's Memorial Medical Center

Harold Henderson replies:

I appreciate Drs. Christoffel and Tanz's comments, but their letter is a persuasive refutation of an article quite different from the one I wrote.

I did mention that guns increase "the lethality of whatever else is going on." In fact I quoted Dr. Christoffel, adding in my own words that "a gun is a labor-saving device." I may be guilty of using "violence" and "crime" interchangeably, but the researchers I cited do not. Dr. Brandon Centerwall in 1991 in the American Journal of Epidemiology found no relation between gun prevalence and homicide rates. No one study is conclusive, but the medical gun-control literature is strangely silent on this one.

Of course the tobacco industry has been trying for decades to pin smokers' health problems on anything but smoking! My point was that the burden of proof against guns is harder to meet than against cigarettes. It's possible that gun ownership causes violence; it's also possible that violence causes people to buy guns. Both hypotheses make sense; both may be true. When you correlate cigarettes and lung cancer, you already know which is the probable cause.

Finally, of course it's legitimate for MDs to have opinions on policy matters, both as citizens and as MDs. But when they speak in public as MDs, they should be held to a higher standard of research and reasonableness. It is not ad hominem to suggest, as I have, that so far the medical case for gun control fails to meet that standard.

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