Dr. Katherine Kaufer Christoffel and Dr. Robert Tanz of Children's Memorial Hospital plan to do to handguns what their profession has done to cigarettes since the 1964 surgeon general's report--and then some. First they want to move the whole discussion of violence out of the realm of politics and into that of science. Then, backed by medical authority and research results, they aim to turn gun ownership from a personal-choice issue to a repulsive, antisocial health hazard. Ultimately, they believe, this process will make it possible to ban handguns with some hope of compliance.
Both Christoffel and Tanz have the air of genial, nonpatronizing authority that marks a successful pediatrician. When I met them in a hospital conference room decorated entirely in shades of white I thought the only questions were: Could they do it? How? And how soon? I took it for granted that the medical case against guns was as solid as the case against smoking. Unfortunately I was mistaken.
Children's campus, at Fullerton, Lincoln, and Halsted, isn't directly in the path of the violence explosion, which is concentrated in poorer neighborhoods and among young adults. But it's close enough. In 1983 the hospital treated three kids for gunshot wounds; last year it treated 33. Christoffel once saw a 16-year-old brought in who'd been shot only 15 minutes earlier. "He was alert but pulseless," she recalls. "I've never forgotten how terrifying it was to watch him actually dying."
After multiple blood transfusions he survived, but in Christoffel's mind he came to stand for a less hopeful trend. "Rates for most other types of injuries have been falling in recent years," she wrote in the April issue of the American Journal of Public Health. Yet "homicide and suicide rates have been stable for the entire population and increasing for young people."
Between 1984 and 1991 violent crime in Chicago rose 47 percent, according to the Illinois Criminal Justice Information Authority, while violent crimes with firearms rose 83 percent, from 18,500 to 37,800. U.S. residents are more than twice as likely to be murdered as people who live in the next most homicidal developed country, Finland. Firearm deaths nationwide--suicides plus homicides plus accidents--are approaching 40,000 a year.
"You can bet that if 40,000 people were dying from cholera, or flesh-eating killer strep, or Schwan's ice cream," says Tanz, "then we'd be doing something to prevent it"--not just treating the carnage and punishing the criminals. As pediatricians, he and Christoffel believe the best way to prevent violence (though not the only one) is to get rid of guns, especially handguns.
Their public-health approach goes beyond simply calling violence an "epidemic" by relying on the science of injury control developed by William Haddon. A doctor who'd studied tropical diseases but couldn't find a job in his specialty, Haddon wound up applying the concepts he'd learned to injuries caused by consumer products. He was so successful at this that you could call him the intellectual godfather of Ralph Nader. Tanz and Christoffel told his story in a 1991 article in The Child's Doctor, where they paraphrased one of his key principles: "Injury control strategies that provide passive protection are always preferred over strategies that require people to act on their own behalf." Thus air bags (which work automatically) are better than seat belts (which must be buckled up each trip, though they then work automatically), which in turn are better than trying to train people to drive defensively (which requires constant alertness and caution). "Rather than deal with the nut behind the wheel, we try to modify the roadway and the car structure," says Christoffel. "It's very hard to reach everyone behind the wheel." And so car fatalities--to which these principles have been applied--steadily decline, while gun fatalities continue to rise.
The injury-control model isn't a perfect fit for the violence problem. Accidents make up a relatively small fraction of firearms killings. Unlike cars, guns are usually dangerous even when used properly. But "passive protection" still works: keeping a gun locked and unloaded (or not having one at all) is thought to be safer than, say, mandatory "gun safety" classes.
This approach is not new to the medical profession. Doctors have been writing about violence in medical journals for at least 20 years. Ten years ago the American Academy of Pediatrics came out in favor of handgun-control legislation that would bring about "the elimination of these guns from the environment of children and adolescents."
But the movement has new momentum these days, in part because the Joyce Foundation is putting money behind it--almost a million dollars in 1993. Part of the new Violent Injury Prevention Center at Children's Hospital is the Handgun Epidemic Lowering Plan (HELP) Network--founded two years ago and funded with $90,000 from Joyce for 1995--a coalition of professionals and organizations that agree that "the private posssession of handguns [is] a major public health emergency."
Christoffel says her audiences are "hungry for an alternative to the obvious inadequacy of relying only on a criminal-justice approach" to violence. And she's already starting to put that alternative into practice. She and two colleagues offered the physician readers of the April 7 issue of Chicago Medicine a system for remembering what questions to ask patients about gun violence. Counseling patients to get rid of their guns, they wrote, "is similar to counseling patients about cigarettes, alcohol, or other preventive medicine issues. These strategies have demonstrated success in changing behavior to prevent disease or injury. For example, 10%-20% of patients who quit smoking say they did so as the result of a physician's recommendation."
"We have to ask the question, does it make you feel safer to have 60 million handguns out there or none?" says Tanz. "Which society do you feel safer in? It's your choice. And if you feel safer with the guy next to you on the el having a gun, you should go see a psychiatrist."
But if gun violence is to be a matter of science and not politics, we have to leave our personal feelings at the door. It shouldn't matter that I have a horror of guns, or that Dr. Christoffel has been a member of the Illinois Committee Against Handgun Violence since 1981, or that as a boy Dr. Tanz shot birds and squirrels with his BB gun.
If you were suffering from a virus, no reputable doctor would give you an antibiotic for it, no matter how bad you felt; antibiotics work only against bacterial infections. So now that we have a nasty violence epidemic, how do we know that gun control will help stop it?
The answer seems obvious, but it's not. When I first mentioned to Dr. Tanz that I'd discovered some reputable criminologists who don't think guns are the key to the violence problem, he snapped, "Well, what do they think is killing people then?"
Sure, guns kill people now. But that doesn't prove that removing them would reduce the killing, any more than outlawing doughnuts would reduce the number of fat people.
Still, it might help. The doctors researching gun violence offer four kinds of evidence that it would:
(1) In places with more guns there's more violence.
(2) At times when there are more guns there's more violence.
(3) People who have guns are more likely to kill than people who have less powerful weapons.
(4) Regardless of anything else, the risks of private gun ownership far exceed the benefits, so even if banning guns doesn't do much good it can't hurt.
Places. If guns cause violence there should be more violence where there are more guns. The U.S. is awash in both guns and violence; Great Britain has comparatively little of either. End of story--except that Switzerland has lots of guns and little violence, and Mexico has few guns and plenty of violence. To learn from such comparisons, you need to control for confounding factors: the failure to do so is the main reason political arguments about gun control tend to be pointless.
An ideal test would compare places that differ only in number of guns. In the November 10, 1988, issue of the New England Journal of Medicine nine doctors led by John Sloan and Arthur Kellermann published "Handgun Regulations, Crime, Assaults, and Homicide: A Tale of Two Cities," which comes reasonably close to the ideal. The authors compared Seattle, Washington, and Vancouver, British Columbia--both port cities with similar populations (just under 500,000), similar climates, similar histories, whose inhabitants enjoy similar educational levels, similar income distributions, and even have similar tastes in TV programming. Both cities are about three-quarters white and 1.5 percent Native American. Vancouver is 22 percent Asian, while Seattle is 7 percent Asian, 10 percent black, and 3 percent Hispanic. According to the best evidence, there are three to four times more guns in Seattle than in Vancouver.
The doctors found that during the seven years from 1980 through 1986 people were robbed, burgled, and assaulted about equally often in the two cities. But aggravated assault and murder were much more common in Seattle--11.3 homicides per 100,000 person-years, compared to only 6.9 in Vancouver. And virtually all of that increased risk of death "was due to a more than fivefold higher rate of homicide by firearms. . . . We conclude that restricting access to handguns may reduce the rate of homicide in a community."
The key word here is "may." The doctors acknowledge that they can't be sure the Pacific Northwest is like the rest of the continent. And, of course, "the current high rates of handgun ownership [in the U.S.] might blunt any effects of tougher handgun regulations for years to come." But the biggest hole in their study could hide an arsenal: within each ethnic group (except Asians), the two cities' homicide rates are statistically equal.
In Seattle homicide rates among blacks and Hispanics are four to six times greater than among whites, but there aren't enough blacks or Hispanics in Vancouver to get reliable comparisons with Seattle for these groups. The murder rates per 100,000 people in Seattle and Vancouver are nearly identical for non-Hispanic whites (6.2 and 6.4) and for Native Americans (64.9 and 71.3).
It fell to Dr. David Stolinsky of Los Angeles to ask the obvious question, in a letter published in a later issue of the journal: "If restricted access to firearms reduces homicide rates, as Sloan et al suggest, why does this factor affect certain groups but not others?" Without actually saying that Sloan et al had jumped to their conclusion, Stolinsky noted that they "could have concluded that the accessibility of firearms had no clear effect on homicide rates, because such an effect would be expected to act on all ethnic and racial groups. They could have gone on to collect data on income, crowding, gang activity, and substance abuse. A multivariate analysis might then reveal which of these factors affect the homicide rate and whether any additional effect is exerted by the accessibility of firearms."
Seattle epidemiologist Dr. Brandon Centerwall took the "place" question in a different direction and compared adjoining U.S. states and Canadian provinces from Maine to the Yukon. His results, published in the American Journal of Epidemiology in 1991, didn't come out as he expected: although there are three to ten times more guns per capita on the U.S. side of the border, homicide rates from 1976 to 1980 were sometimes higher on one side, sometimes on the other, in an apparently random pattern. (He says that a parallel study of suicides, as yet unpublished, shows the same lack of pattern.)
"Homicide rates along the US-Canadian border primarily reflect underlying rates of aggravated assault, and Canadians are as assaultive as their US neighbors," Centerwall wrote in conclusion. "Canadians fully compensate for the relative dearth of handguns in Canada by effectively utilizing other means for killing one another. It can be presumed that Americans would be no less resourceful under comparable circumstances. . . . If you are surprised by this finding, so am I. I did not begin this research with any intent to 'exonerate' handguns, but there it is--a negative finding . . . that directs us where not to aim public health resources." (Centerwall's finding might not astonish those who read criminology journals as well as medical ones. Back in 1979 in the Law & Policy Quarterly Alan Lizotte and University of Illinois sociologist David Bordua carefully compared gun ownership and crime in the 102 counties of Illinois and found that "where the rate of legal firearms ownership is high, the crime rate is low.")
I asked Centerwall if he could be putting too much emphasis on a negative result, given that he couldn't include cities of over 500,000 and given that gun-ownership data by state are dicey at best. No, he replied firmly. "It's not as though the data were in the direction of showing an effect and just missed statistical significance. They're not even close."
The most intriguing thing about Centerwall's article, however, is the obscurity to which it's been relegated. In scientific disputes, from earth science to psychology, it's customary to refer to previous studies of the subject, explaining how yours adds to, contradicts, or (usually) improves upon them. In fact, that's how I originally worked the library for this story: starting with the footnotes in Dr. Christoffel's own articles, I looked up the articles she'd cited, followed their footnotes, and soon got a good idea of what was in the network. But I could have spent weeks poring over the New England Journal of Medicine and the Journal of the American Medical Association and never learned of Dr. Centerwall's work. (Dr. Tanz told me later that he'd heard it was coming but didn't know it was out.) Even though it appeared in a respected public-health journal and its author's other work is often cited by his colleagues, this particular piece might as well have been "published" in Chicago's northwest incinerator. "I don't think I've ever seen it cited or discussed," he told me. "If they [the pro-gun-control doctors] felt they could simply trash my research they wouldn't hesitate to do so. But you don't discuss what you can't deal with."
Times. If guns cause violence then stiff laws against them should reduce violent crime, so another approach would be to compare the same place before and after such legislation was passed. In 1976 Washington, D.C., passed a law banning civilian purchase, sale, transfer, or possession of handguns. In 1991 in the New England Journal of Medicine criminologist Colin Loftin and three colleagues reported that the average number of D.C. homicides before the law (1968-'76) was 13 per month. After the law (1977-'88) it was only 9.7 per month. (Suicides declined less.) Even more impressive, the authors found no similar decline in Maryland or Virginia (whose gun laws stayed the same). "Our data suggest that restrictions on access to guns in the District of Columbia prevented an average of 47 deaths each year after the law was implemented."
These results seem almost too good to be true, since local gun-control laws are thought to be largely symbolic. After all, guns can always be bought in the next state, and the District of Columbia is as close to the next state as Indiana is to Hegewisch. And the results may in fact be too good to be true, since--according to the graph published in the article--the monthly D.C. homicide rate had begun to drop two years before the law was passed.
Was the law instantly effective against high geographic odds? Or had something else already caused the murder rate to start dropping? Or, to put the question another way, if all you had was the graph of the monthly murder count could you deduce when the handgun ban was passed? "I can't answer that question," Loftin said when I asked him. "My guess is you could probably tell, but I don't claim to know why. What you see [on the graph] is what you get. The point is, we don't know very much about this stuff. This was a dramatic change in policy, and it made sense to look at it. That's what we found. But I don't know if it would happen that way again."
People. No one can deny that a gun is a labor-saving device. "It's hard work to kill somebody with a knife or your fists," says Dr. Christoffel. So fewer guns should mean fewer murders, right? That depends on how you think murders happen. To oversimplify dangerously, there's the average-Joe theory and there's the predator theory. An average-Joe murder happens when an argument escalates out of control and becomes homicidal, most often because the handiest weapon is a gun rather than a frying pan. A predatory murder happens as part of the life-style of someone for whom (in the words of Northwestern University law professor Daniel Polsby) "predation is a rational occupational choice"--someone who would defy gun prohibition with the same determination and success that drug dealers now defy drug prohibition.
In the April American Journal of Public Health Christoffel published a complex, arrow-filled diagram of the factors she thinks contribute to "peer assaults," the most common event leading up to murders. "I divided the chart into two parts," she explains. The top part has root causes of attacks between peers, including social and community problems, personal dysfunction, family dysfunction, coping repertoire, alcohol, and drugs. The bottom, dark-shaded quarter of the diagram shows just one factor determining the lethality of those attacks--the weapon used.
The week I spoke with Tanz and Christoffel a jilted lover in Skokie had just shot his estranged wife and her new boyfriend, then killed himself. The two doctors believe this is typical. Says Christoffel, "Most handgun shootings are between friends." Or, as four doctors wrote in Issues in Science and Technology in 1991, "The overwhelming majority of people who shoot to kill are not convicted felons; in fact, most would be considered law-abiding citizens prior to their pulling the trigger."
Presumably, the more murders follow this pattern, the more good eliminating guns will do. But the more murders are committed by predators, the less difference gun-control laws are likely to make.
So which scenario is more often true? Chicago police figures do not support the doctors' claims. Most killings here are not "friends and family." According to the Chicago Police Department Detective Division's 1993 "Murder Analysis" of the 850 city killings that year, only 53 involved family members. Only 74--less than 10 percent--involved "friends" of any kind. Far more numerous were cases where victim and offender were unrelated (216) or had "some acquaintanceship" (212). Also contrary to the doctors' statement, 72 percent of Chicago's 1993 murderers had prior criminal histories (as did 59 percent of their victims). Figures for earlier years are similar.
However, the police numbers don't unequivocally support the predator theory either. The largest single cause of killings is listed as "altercations." And if you add together murders involving friends, family, and acquaintances (a loose category to be sure), they make up 339 of the 510 murders in which the relationship could be determined. Moreover, in her 1986 book Homicide in Chicago Carolyn Block notes that homicide isn't one crime but many and that "homicides that begin as assaults differ from homicides that begin as robberies in a number of ways." She points out that, with important exceptions, assault homicides tend to be "impulsive" (the average-Joe theory), while most robbery homicides are "instrumental" (the predator theory). Between 1965 and 1981 Chicago had 8,893 assault homicides and only 2,164 robbery homicides.
But maybe it doesn't matter which kind of murder is most common. The average-Joe theory predicts that, other things being equal, more guns mean more spouse murders. Two Centers for Disease Control epidemiologists--who themselves hold to the average-Joe theory--reviewed statistics in the American Journal of Public Health (May 1989) and found that spousal homicide had declined for blacks and remained stable for whites between 1976 and 1985. Yet during that same period, handgun ownership in the U.S. rose from roughly 200 to 260 per 1,000 people.
Risks. But aren't all these arguments just perverse delaying tactics? Why should we treat guns like human defendants, innocent until proved guilty? Clearly plenty of killings do follow the average-Joe pattern. Serious gun control would eventually reduce their numbers, and whom would it hurt?
The risks of gun ownership are the subject of a series of well-known public-health studies, the most recent and arguably the most sophisticated of which appeared in the October 7, 1993, New England Journal of Medicine. Its ten authors, led by Dr. Arthur Kellermann and Dr. Frederick Rivara, looked at 316 killings in homes in and around Seattle, Cleveland, and Memphis. They carefully matched each victim with a control similar in age, sex, race, and residential neighborhood. Comparing victims and controls statistically, they found six factors "strongly and independently associated with an increased risk of homicide in the home":
living in a rented house,
living with someone who'd been hit or hurt in a fight at home,
living with someone who'd been arrested,
living with someone who used illicit drugs, and
living in a home containing one or more guns.
The authors concluded that "protective gun" is an oxymoron. "People should be strongly discouraged from keeping guns in their homes." But they wisely refrained from urging renters to protect themselves by buying a home ASAP. Chances are that renting doesn't cause you to get shot--something else, like being poor, is likely to cause people to both rent and get shot.
Similarly, something else could well cause people to buy guns and get shot. As the authors acknowledge, people who are threatened with homicide may be more likely to buy guns. And people who are psychologically prone to violence may be more likely to buy guns.
The NRA line, of course, is that guns prevent crime by scaring off criminals. That's hard to prove too, since such episodes aren't counted by police and surveys in which people are asked about them disagree wildly. (New England Journal articles on this point are no help: they look only for the rare cases in which a would-be housebreaker is shot.) An anonymous telephone poll of a large representative sample conducted by Florida State University criminologist Gary Kleck yielded an estimate of more than two million cases a year in which people said they scared off a criminal with a gun (usually not firing it). The federal government's National Crime Victimization Survey, conducted in person, estimates only about 80,000 such cases a year--an enormous discrepancy. Dr. Tanz acknowledges that he has never read a word Kleck has written, but he prefers the government numbers "because they use established and accepted methods."
This is a crucial point. If guns do deter a significant number of some crimes, then getting rid of them could be counterproductive. Tanz agrees: "If somebody were to turn around and prove that guns save more lives than they kill, then I think we [gun-control advocates] would have to turn around and reconsider." He'll have a chance to check out Kleck's methodology next summer, when Kleck's results will appear in the Journal of Crime and Criminology.
Of course no study is perfect; the conviction of tobacco as a health hazard no doubt began with initial research indictments that were full of holes too. But guns are harder to convict precisely because they're a social problem, not a medical one. If you can correlate lung cancer and cigarettes you have a pretty fair case against cigarettes. The causal arrow will run only one way. (Not even the most demented RJR lobbyist ever argued that lung cancer causes cigarettes.) But it could run either way with guns: they may cause crime, yet there's a good deal of evidence from criminology that (fear of) violent crime causes people to buy guns.
The tobacco analogy is a favorite among doctors, including Tanz and Christoffel, who estimate that guns are in roughly the same position in society today that tobacco was 30 years ago. And they do not want to see legal bans enacted before sufficient public revulsion has built up. "If we could magically ban handguns tomorrow, it would have little effect," says Christoffel. "We have to work toward it in such a way that it consolidates something happening in society." Tanz explains: "If in 1965 you had tried to ban smoking on airplanes or have no-smoking areas in restaurants, you'd have been laughed at. It took 20-plus years for society as a whole to embrace the idea of protecting people that way. It took a long time, a lot of little tiny steps and arcane matters. Finally people said, 'Of course you can't have smoking in these tiny conference rooms.'"
But guns are already as unfashionable as cigarettes in white upper-middle-class circles. If low-income people are the most vulnerable to gun violence (as is generally agreed), it has to be discouraging to realize that they're also the most recalcitrant smokers. This is no reason to give up if research eventually convicts guns, but it is reason to expect very slow results.
Public-health people often complain that the gun lobby has prevented proper funding of research on guns. (The Consumer Product Safety Commission, for instance, is forbidden by law from regulating guns or ammunition in any way.) But they rarely refer to research on crime, violence, and guns conducted by nonmedical professionals. In 1983 sociologists James Wright, Peter Rossi, and Kathleen Daly (in a book titled Under the Gun) surveyed all the research up to that time and found little or no evidence that gun control would reduce violence. Criminologist Gary Kleck's 1991 magnum opus, Point Blank: Guns and Violence in America, is more controversial. But to the casual reader his methods seem careful, and his findings don't seem tailored to fit either the NRA or the gun-control agenda. The NRA's favorite get-tough-with-criminals approaches, he summarizes, "have been tried, carefully evaluated, and found to be either ineffective in producing significant crime reductions or hopelessly expensive." Yet he also points out that the gun controllers' panacea--limiting ownership of handguns only--might be counterproductive because it could "increase the gun death total by encouraging the substitution of more lethal types of guns."
Among noncasual readers Kleck's book also passed muster, winning a prize from the American Society of Criminology. Writing in the Social Service Review, gun-control supporter Thomas Regulus of Loyola described it as "a thoughtful scholarly study that is must reading for proponents and opponents." Like some of Kleck's other colleagues, Regulus thought that Kleck's conclusions sometimes determined his arguments instead of the other way around. Such an accusation might also be leveled at the pro-gun-control medical research. As Dr. Centerwall cautioned when I said something naive, "I think you'll discover that the realm of science is not free from people's political thoughts and agendas."
Do doctors know enough to prescribe to us about guns? Yes and no. The gun issue is something like the nuclear-weapons issue. Medical research contributed to the 1963 nuclear test ban treaty by showing that strontium 90 from such tests was being found in the baby teeth of children everywhere. Similarly, a 1991 article in the Journal of the American Medical Association by Dr. David Brent and others found that "the general controversy regarding gun licensure and ownership notwithstanding, it is clear that firearms have no place in the homes of psychiatrically troubled adolescents. Inquiry about the presence and method of storage of firearms in the homes of young patients should become a routine part of general pediatric and psychiatric care."
It's not so clear that being a doctor makes you an expert on the surrounding policy issues. During the cold war Physicians for Social Responsibility was convinced that nuclear deterrence meant national suicide, and Dr. Helen Caldicott predicted that Reagan's reelection in 1984 would guarantee nuclear war. Nevertheless, the doctors have the white-coat reputation, the foundation money, the media support, and the long-term plan. For their sake and ours, let's hope they eventually get the evidence as well.
Art accompanying story in printed newspaper (not available in this archive): illustration/David K. Nelson.