43. Contagion

April 25, 2006

Hall of the House of Representatives — Washington, D.C.

The retired nurse from New York returned to the podium on the House floor. “Last week the Centers for Disease Control released a report on the economic burden of injuries in the United States,” she said. “The results were astonishing.” She described how, as part of the project, the CDC had added up all the health care costs, lost wages, and lost productivity that were due to injuries (accidents or otherwise) to Americans in one year: the total came to $406 billion.

Supporting that price tag was an exhaustive report, laying out detailed statistics behind all of the categories of injuries it studied — from falls, to fires, to car accidents, to sports injuries. But, as the representative from New York pointed out, there was just one blind spot in the data: “There is no listing on the costs of gun violence. [And] the public might ask, ‘how could the CDC avoid gun violence when listing the causes of serious injury in this country?’ The answer is simple: Congress won’t let them.”

* * *

The federal agency that would become known as the CDC had been around in some form since 1946, when it was called the Communicable Disease Center; it was just after the surrender of Imperial Japan, when the federal government was transitioning back to a peacetime footing, and they wanted to hang on to the many scientific advancements brought by the war effort. There had been major developments in medical techniques, particularly in combating malaria, that would be invaluable in the southeast United States; the unconventional location of the agency’s headquarters — to this day in Atlanta, Georgia, rather than Washington D.C. — is a lasting reminder of this founding purpose.

But by 1951, malaria was effectively eliminated in the country. The US, again, was not about to just give up such a effective operation, and so the Communicable Diseases Center expanded its scope, to address all diseases. Then, in 1970, the organization’s name was officially changed to the Center for Disease Control.

The CDC experienced the most fundamental shift yet in its purpose in 1979, when the Surgeon General released Healthy People — an in-depth status report on the health of the American populace, and confirmation of just how far the medical community had come in the last century. Healthy People showed that Americans were living longer, thanks significantly to institutions like the CDC: its bar graphs listed causes of death since 1900, and one could see plainly the infant mortality rate plummeting over time, as sanitation standards rose. Polio, typhus, malaria, smallpox, cholera, tuberculosis, simple bacterial infections… the scourges of previous generations had largely been conquered. State-coordinated vaccine programs, and development of antibiotics, completely changed how Americans experienced disease. And in the 1960s, the CDC had played a key role in one of the greatest achievements in the history of public health: the global eradication of smallpox.

Based on Healthy People, the CDC, as of 1979, needed to again reassess its purpose: to become almost a post-disease Center for Disease Control. Because while the biological threats had decreased over the years, injuries had steadily moved to the top of the list for causes of death — and yet, most Americans were not tripping and falling (or having something fall on them, or getting in an auto accident, or burning themselves) any more frequently than they had before. Instead, the increases were associated with two things: young people, and violence — young men, especially. Out of the over-21,000 Americans who were victims of homicide in 1977, about 25 percent were aged 15 to 24, and they were five times more likely to be male than female. Six percent of deaths for white Americans in this age group were from homicides; for blacks, it was thirty percent. “Easy access to firearms appears to be the one factor with a striking relationship to murder,” the CDC wrote. “From 1960 to 1974, handgun sales quadrupled to more than six million a year. During that same period, the homicide rate increased from 4.7 per 100,000 to 10.2 for the overall population — and from 5.9 to 14.2 for young people aged 15 to 24.” In other words, the most urgent biological threat to humans increasingly appeared to be other humans, and so the prevention of violence started to be viewed as a valid area of research for an organization like the CDC.

The National Research Council followed up with its own, similar study in 1985, Injury in America — and this was what first set into motion the series of events that would bring the CDC into the fight over guns.

Assembled by the Committee on Trauma Research, this latest report exposed that “injuries destroy the health, lives, and livelihoods of millions of people, yet they receive scant attention, compared with diseases and other hazards.” More than 140,000 Americans were dying from injury — accidental or intentional — each year. And in particular, the report continued, “Injury is the last major plague of the young. Injuries kill more Americans aged 1–34 than all diseases combined, and they are the leading cause of death up to the age of 44.”

There was a broad consensus in the research community — the same that had defeated so many scourges of public health — that something now had to be done about injuries. The research council and the Institute of Medicine decided that the CDC would be the ideal agency to take up the charge, partly because of how limited they were; being essentially a group of scientists and doctors, tasked with researching threats, the CDC can only make recommendations, not laws. They were, ostensibly, apolitical.

* * *

Meanwhile, the CDC’s name had been pluralized to Centers for Disease Control, signifying the organization’s broadening focus. (A few years later, they added “and Prevention” to the end of the title — but the agency would continue to go by “CDC.”) While the older departments at the CDC continued funding lab work, successfully identifying the causes of both Legionnaires disease and toxic shock syndrome (and at the same remaining tragically inattentive to the symptoms of the AIDS epidemic in the early 1980s), new teams were setting up shop to focus on studying injury.

It was immediately obvious to the researchers that they would be looking at the role that guns played in the nation’s injury and murder rates; they were epidemiologists, and that’s where the data led. “Clearly,” one researcher said, “if three fourths of homicides are caused by firearms, we have to look at their role.”

In 1989, the Secretary of the U.S. Department of Health & Human Services released a report from their “Task Force on Youth Suicide.” It carried still more bad news about guns, and young men: since 1975, there had been an astonishing rise in the suicide rate for males between ages 15 and 19 — almost triple — and the rise coincided with the already-known increase in national handgun sales. “Guns now account for more suicides than all other methods combined,” the researchers said. “65 percent of teen suicides are committed with firearms. An environmental risk-reduction strategy would call for decreasing the availability of handguns.”

It did, increasingly, sound like a campaign for gun control. “Some 25 million households have handguns and one-half of these keep their handguns loaded,” one of the commissioned papers attached to the report read. “Adolescents are impulsive. Having a loaded handgun around the house is an invitation to disaster.” The Surgeon General encouraged more research on the subject, and the CDC directed more funds accordingly.

* * *

In 1992, the CDC officially established the National Center for Injury Prevention and Control (the very organization that would eventually produce the price tag that so shocked the congresswoman from New York in 2006). At first, they focused on supporting state and local efforts to advocate against drunk driving, and to encourage the use of seat belts. That got results; so then, they pivoted to the next item on the list for injuries: guns.

In a letter published in the Journal of the American Medical Association, signed by three of the CDC’s doctors, the organization predicted, “Just as we were able to save countless lives from motor vehicle injuries without banning cars, we can save many lives from firearm injuries without a total ban on firearms.”

The push-back was immediate; their wording seemed to imply that a partial ban on guns might be on the way. And it didn’t matter that the CDC had no power to enact such a ban, partial or otherwise; now the CDC had the NRA’s attention.

The last straw came in October 1993, in an article from the New England Journal of Medicine: “Gun Ownership as a Risk Factor for Homicide in the Home.” The researchers (based at Emory University, and funded by the Injury Prevention Network) looked at homicide statistics from three major cities — Seattle, Memphis, and Cleveland, including their surrounding counties — in the period between 1987 and 1992. What they found suggested that ownership of a firearm for home protection might actually be, strictly based on the numbers, a rather stupid investment. In total, they found 420 homicides in which the victim was killed at their home. But in 85 percent of those cases, there was no forced entry — so the “home defense” gun owner had never been in a position to defend themselves when their day finally came. Furthermore, their average attacker was not a masked gunman or escaped convict; in 76 percent of the cases, the murderer was someone the victim knew. Often a family member. Only 3 percent were known to have been killed by a stranger. (Though there was some elasticity in this figure — since in 17 percent of the cases, police never identified a killer.) Meanwhile, nearly half of the victims were killed with a gun, the most lethal implement by far.

The NRA criticized the “New England study” the day it came out. They argued that it wasn’t really giving the full picture: a gun was supposed to deter a homicide of the person living in the home, and so the cases where it worked as intended were all excluded from the study. It was a valid point, but one that also ignored the separate set of risk-factor statistics — which showed that guns, by themselves, increased the danger level in a home. Eliminating all other factors, simply having a gun in the home nearly tripled the likelihood that someone who lived in the home would be killed. It was the third most significant risk factor they found (behind only illegal drugs and — by far the most significant factor — domestic violence). “This study is the first to clearly link the risk of homicide to the immediate availability of a gun,” said the lead researcher from Emory to the New York Times. “In light of these results, people who are considering buying a gun for protection should think again. And families who keep guns in their homes should strongly consider getting them out of the house.”

The NRA tried to get the Injury Prevention Network shut down, exerting its many appendages of political force all through 1994. But the center survived. The old gun lobby’s powers were at an ebb, then — California had just passed their gun ban, and both the federal assault weapons ban and the Brady Bill were making progress under Clinton. The NRA’s savior, Charlton Heston, had yet to arrive. It looked like the CDC had them beat.

Then, in 1995, the Injury Prevention Network — suddenly, and for no coherent reason — gave the NRA exactly what it was looking for. The spring issue of the IPN Newsletter — with the cover story “Women, Guns and Domestic Violence” illustrated by a handgun blasting away pieces of a ♀ symbol — included an article entitled “What Advocates Can Do.” The advice it gave (intended for research professionals and public health staff) was blatantly political: “Put gun control on the agenda of your civic or professional organization. Release a statement to the media or explain in your organization’s newsletter why gun control is a woman’s (or nurses’ or pediatricians’…) issue.”

The pamphlet further encouraged readers to “make your support for federal, state, and local gun laws known to your representative,” which might entail “opposing repeal of the assault weapons ban; maintaining support for the Brady Law; restricting ammunition availability by caliber and quantity; increasing enforcement of federal firearm laws; maintaining restrictions on issuance of concealed weapons permits…” and the pamphlet just kept going. It told the reader how to organize a picket line outside of a gun factory, and advocated campaign finance reform that would “weaken the gun lobby’s political clout.” It was everything the NRA had claimed the CDC secretly wanted to do — and right out in the open.

* * *

In October 1995, eight NRA-aligned senators released a public letter, declaring that the CDC’s Injury Prevention Network was wasteful, biased, and driven by “preordained political goals and not from the desire for scientific, balanced and unbiased inquiry.” The senators publicly declared, “This CDC program can be cut with no diminution of service in administering the public interest, and at a savings to the taxpayer.”

Soon, a hearing with the House Subcommittee on Labor, Health and Human Services, and Education was scheduled, where a representative from “Doctors for Responsible Gun Ownership” gave testimony bashing the CDC’s methods. The former surgeon (and lifetime “Benefactor member” of the NRA) held up a copy of the now-infamous newsletter, for all to see. “I would be just as vocal about this if this were a pro-gun issue,” the doctor said. “Anti-gun, pro-gun, it is still wrong to alter science to serve a biased agenda. Period.”

Behind closed doors, the CDC’s opponents in Congress were finalizing their attack plan. They would indeed focus on the CDC’s funding, located in the 1996 budget appropriations: right in the middle of routine provisions for things like education for refugees, and facilities maintenance, their amendment would add the sentence:

…Provided further, That none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention be used to advocate or promote gun control.

The congressman from Arkansas who sponsored the amendment in the House — a lifetime member of the NRA, named Jay Dickey — first sounded the alarm to his colleagues on July 11, 1996:

…this is an issue of federally funded political advocacy. We have here an attempt by the [CDC] to bring about gun control advocacy all over the United States. […] Rather than calling violence a disease and guns a germ, these people should be looking at the other root causes of crime: Poverty, drug trade, gangs, and children growing up without parental support, and the cruel trap of welfare dependency.

The “Dickey Amendment,” as it came to be know, was passed. And while the language of the amendment only seemed to block the use of funds to “advocate or promote gun control” — not the research of firearms injuries, like the New England study — the CDC’s opponents also managed to earmark $2.6 million of the agency’s budget (the exact figure that the NCIPC had spent on researching firearms injuries the year before) and set it aside for other research. The amendment might not have been a “ban” on studying guns, but in practice, that’s exactly what it became. “Precisely what was or was not permitted under the clause was unclear,” the New England study’s lead researcher would later write, “but no federal employee was willing to risk his or her career or the agency’s funding to find out. Extramural support for firearm injury prevention research quickly dried up.”

* * *

It wasn’t until 2006 that a member of Congress introduced legislation that would repeal the Dickey Amendment. And that was why the nurse from New York was at the podium then, expressing her shock and outrage at the price tag for injuries to Americans, absent any research on guns. She wanted the amendment gone.

But the 2006 repeal ultimately failed, and the Dickey Amendment stayed right where it was. The Committee only added some guidance when it came to researching guns — that they “understand that CDC’s responsibility in this area is primarily data collection and the dissemination of that information, and expect that research in this area to be objective and grants to be awarded through an impartial, scientific peer review process.” But they still didn’t restore any of the funding for such research that had been cut back when the Dickey Amendment first passed. And so nothing was going to change.

The nurse from New Jersey finished her remarks, and went back to her seat. She already knew the CDC wasn’t going to take any risks; it was as if the agency itself had been traumatized from its reckoning with the NRA, and had adopted its own avoidant behavior as a result. The result was a unique set of circumstances for such a heavily-armed society: if indeed guns made school shootings, or mass shootings, more likely to happen, Americans would be the first to experience the phenomenon — and the last to understand it.