After having read what I considered to be poor-quality articles regarding Gun Control, published in the

Annals of Internal Medicine, I wrote a letter-to-the-editor; today, it was published and, therefore, it is
desirable to provide primary-data to permit a fair and balanced review of my critique and responses
from both authors. Curiously, the structure of what usually occurs in such instances was supplanted by
sandwiching my letter between the authors of the primary article [a lengthy elaboration upon its
rationale, absent reference to my critique thereof] and of the editorial [a more deferential defense of
the opinions ensconced therein]; customarily, the criticism is followed by replies from the authors.
Again, here is what I wrote:

TO THE EDITOR:

Because public health research predictably guides a generation of public policy, it is
necessary to scrutinize the political science underlying the paired systematic review (1)
and editorial (2) on gun control. Challenges are detected to fundamental standards that
may compromise an otherwise sound meta-analysis of available literature. The last
sentences of each are revelatory. Anglemyer and colleagues' review finds restricting
[access to a firearm in the home] may effectively prevent injury (1), and Hemenway's
accompanying editorial concludes that obtaining a firearm not only endangers those
living in the home but also imposes substantial costs on the community (2).
Notwithstanding unaddressed Second Amendment constraints, the authors of both
unabashedly campaign to restrict the right to bear arms, thereby ignoring, for example,
the human compulsion to manifest reasonable self-defense.

The intuitive deduction that the availability of a firearm will increase the risk that
momentary depression will yield suicide is consistent with modern lay culture (recalling
the 1945 movie Spellbound) and medical scholarship (recalling an essay published last
year in Annals [3]). Yet, it is undermined by the editorialist, who has argued that the
widespread ownership of firearms in private hands in the United States promotes the
spread of the disease of gun violence (4). He invoked a generalized reference to his
book when claiming, There is no association between gun ownership levels and suicide
by means other than guns. These studies have controlled for ... depression [and] suicidal
ideation. If true, this assertion would undermine efforts to include scrutiny of mental
health data during any mandated background checks; alas, it is untrue, because profiles
of psychiatric patients at high risk for suicide have been generated (5).

In Anglemyer and colleagues' review, the study by Brent and colleagues was among the
articles cited (reference 26), prompting confusion because it was among 3 articles cited
in the online Appendix that purports to show the disposition of studies excluded after
full-text review along with 2 others (references 32 and 60) because the study
populations were contained in previously published data included in this review (1).
Noting that there are 59 print references and 97 online references, merely counting the
number of citations associated with a particular reason for exclusion yields the
observation that there is an admixture of articles that were included and articles that
were excluded (that is, some were among the references published in print and at least
1 was among those published online only). The authors should have provided a
crosswalk pairing of how one set of data was subsuming another set of myriad peer-
reviewed studies, precluding concern that any undue selectivity existed.

Therefore, author biasseeking the ability to generate the above preordained
outcomecould have clouded how subsidiary observations were drawn regarding, for
example, the allegation of enhanced risk for homicide by a household member.
Adopting a purely academic approach could have yielded insights as to the type of
mental health diagnoses that might predispose to criminal gun use. Indeed, this entire
body of work could then have been compared/contrasted with fatal violence committed
via nonhousehold unregistered firearms, yielding far more useful insights into which
societal interventions might be optimal.

References

1
Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide
and homicide victimization among household members: a systematic review and meta-
analysis. Ann Intern Med. 2014; 160:101-10.

PubMed
CrossRef

2
Hemenway D. Guns, suicide, and homicide: individual-level versus population-level
studies [Editorial]. Ann Intern Med. 2014; 160:134-5.

PubMed
CrossRef

3
Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental
illness: putting compassion before fear. Ann Intern Med. 2013; 159:423-4.

PubMed
CrossRef

4
Wheeler TJ. Book review: Private Guns, Private Health. The Freeman. 2005.

5
Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and
adolescent suicide. A community case-control study. Am J Dis Child. 1993; 147:1066-
71.

PubMed
CrossRef

Because a subscription is needed to access the reactions of the authors, they are reprinted herein:

TO THE EDITOR:

In Hemenway's editorial (1), he correctly suggests that our systematic review and meta-
analysis (2) provides too conservative an estimate of the relationship among guns and
suicide and homicide at a societal level (1). Although we agree that our methods have
probably underestimated the true relationship between guns and suicide or homicide
victimization, our inclusion of only studies that assessed the individual's personal
firearm experience does provide an estimate of the minimum likely risk.

The narrative around studies of firearm ownership and harms usually discredits causality
assumptions, and causal inference is particularly problematic in ecologic studies. Critics
are quick to point out conflicting evidence from various sources of rates and their
interpretations. In fact, a commonly cited review of ecologic data by Kates and Mauser
(3) only adds fodder to the ongoing debate. We purposefully excluded ecologic data, in
part, to obviate this common critique regarding the interpretability of population-level
data.

Hemenway also correctly points out that most individuals commit suicide with a firearm
from their own home, thus potentially justifying the use of aggregate population-level
data to determine suicide outcomes. Unfortunately, this would probably not be enough
to convince doubters that rate data can be used to assert correlations between firearm
access and suicide. More important, we had 2 primary outcomes of interest in our
review: suicide and homicide victimization. Although we can make a reasonable
assumption that the firearms used in suicides were obtained from the home (albeit still
an assumption that we wanted to avoid), we cannot reasonably make that same
assumption about the firearms used in homicides. Hemenway even writes most
perpetrators [of homicides] do not use a gun from the victim's home (1). We feel that
using different inclusion criteria for different outcomes would not have been prudent
(that is, including ecologic data for suicide outcomes and not for homicide outcomes)
because the focus of our review was access to firearms among cases, not among
perpetrators, and the result focuses on the home. Moreover, our results may help
households understand the risks of keeping a firearm in the home, particularly if there is
a household member who is depressed or a violent relationship; results from ecologic
studies may be better for evaluating policies.

Notwithstanding our review, ecologic studies are a good source of data for establishing
trends and positing relationships. We agree that a potential future methodological
review could compare the summary estimates we obtained from individual-level data
with those that would have been obtained if ecologic data been included. Operationally,
of course, a reviewer would need to consider many issues: the rates of ownership to use
(such as regional rates, state rates, or city rates), the time frame (that is, the most
recent or most reliable data), and the types of suicide (for example, should only firearm-
related suicides be included?). For these reasons, among others, ecologic data are
seldom seen in meta-analyses of individual-level data. Assuming that the reviewer was
able to overcome the operational obstacles of disparate rates over disparate regions
describing dissimilar outcomes, he or she would have to ensure that the interpretation
of the results from such a review are truly reflective of aggregated population-level data
and not of individual-level data. Of course, there are conceptual steps to calculate
ecologic relative risk estimates so that conclusions about individual-level behavior can
be inferred, although there are inherent assumptions (4). The reviewer could pool these
new individual-level relative risk estimates to get a pooled rate from ecologic studies.

To compare results from the meta-analysis of ecologic studies with those from the
individual-level data we summarize, there are many approaches a reviewer could use.
Namely, he or she could pool the results together to get a summary estimate from both
ecologic and individual-level data, although combining estimates that were derived from
different sources with different assumptions can be problematic. He or she could also
perform a sensitivity analysis comparing the pooled estimates with and without ecologic
data. Or he or she could perform a subgroup analysis comparing the pooled estimates
from ecologic data with those from individual-level data separately. We feel that there
are indeed benefits from reviewing ecologic data, and Hemenway's suggestion for
future research will complement our current review nicely. The 2 reviews together could
provide a more nuanced understanding of the true relationship between access to
firearms and harms outcomes.

References

1
Hemenway D. Guns, suicide, and homicide: individual-level versus population-level
studies [Editorial]. Ann Intern Med. 2014; 160:134-5.

PubMed
CrossRef

2
Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide
and homicide victimization among household members: a systematic review and meta-
analysis. Ann Intern Med. 2014; 160:101-10.

PubMed
CrossRef

3
Kates DB, Mauser G. Would banning firearms reduce murder and suicide? A review of
international and some domestic evidence. Harv J Law Public Policy. 2007; 30:649-94.

4
Schuessler AA. Ecological inference. Proc Natl Acad Sci U S A. 1999; 96:10578-81.
PubMed
CrossRef

*

IN RESPONSE:

I disagree with Dr. Sklaroff's statements concerning my editorial. My concluding
comment that obtaining a firearm not only endangers those living in the home but also
imposes substantial costs on the community is a statement concerning my synthesis of
the available scientific evidence. It is not a policy statement, and not an unabashed
campaign to restrict the right to bear arms. Indeed, elsewhere I have suggested policies
that could reduce firearm injuries in the United States while keeping nearly all of the
recreational and self-defense benefits of firearms (1). Polls have found that the
overwhelming majority of Americans and most gun owners are in favor of virtually all
such policies (1).

Dr. Sklaroff incorrectly claims that I argue that widespread ownership of firearms in
private hands in the United States promotes the spread of the disease of gun violence.
I am not a physician, and I did not use and do not believe I have ever used the
metaphorical phrase disease of gun violence. Elsewhere, I have reviewed the scientific
evidence on guns and homicide (2). All things equal, where there are higher levels of
gun ownership and weaker gun laws, there are higher rates of homicide due to higher
rates of gun homicide (3).

I accurately summarized the evidence from population-based studies: There is no
association between gun ownership levels and suicide by means other than guns. These
studies have controlled for such factors as ... depression, suicidal ideation, and suicide
attempts. On the basis of that statement, Dr. Sklaroff commented that If true, this
assertion would undermine efforts to include scrutiny of mental health data during any
mandated background checks. In fact, I said nothing about the relationship between
depression or suicide ideation or suicide attempts and suicideI only said that they
were used as control variables. Furthermore, even if no relationship were found
between these control variables and suicide at the ecologic level, it would not mean
that there is no relationship at the individual levelthat is the ecologic fallacy. For
example, if there were no variation in rates of depression across the United States, then
depression could not be used as a factor to explain the variation in rates of suicide. But
that would not mean that depression was not an individual risk factor for suicide.

References

1
Hemenway D. Private Guns, Public Health. Ann Arbor, MI: Univ Michigan Pr; 2006.

2
Hepburn LM, Hemenway D. Firearm availability and homicide: a review of the
literature. Aggress Violent Behav. 2004; 9:417-40.

CrossRef

3
Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R. Firearm legislation and
firearm-related fatalities in the United States. JAMA Intern Med. 2013; 173:732-40.

PubMed
CrossRef

Lets analyze what transpired, here. First, neither confronted the key legal concern that I unambiguously
raised, namely, the existence of the 2
nd
Amendment. Second, neither transcends the ovious fact that the
ability to access a firearm in a home may increase its usage, to both productive and destructive ends.
Third, the author of the review-article expends considerable energy discussing the myriad structures of
potential studies, while the author of the editorial defends his use of the word disease by claiming, in
retrospect,that this term was not actually to be interpreted in its common, medically-oriented fashion
because he isnt a physician. Fourth, the author of the review-article didnt rectify the charge that he
had engaged in selective-citation of the reviewed-literature [painstakingly detailed without provoking
MEGO my eyes glaze-over], and the author of the editorial didnt deign to defend extreme-quotes
that had been carefully lifted from his book. Fifth, neither confronted the major challenge facing those
who would restrict gun-purchases, namely, how their acquisition might be justifiably and fairly restricted
from people who had demonstrated mental illness.

Thus, my critique of the science behind these articles stands, and this information
will be conveyed to an activist who edits guns and patriots, Neil W. McCabe, because I
suspect it may become necessary to be able to rebut efforts to invoke those two pieces
if/when legislation is promulgated.

I might add that two articles are of-interest that emerged today; a Son Used a Handgun To Save his
Mom From an Hammer-Wielding Attacker and, notwithstanding Bloombergs ongoing initiative,
apparently Red State Dems are asking Gabby Giffords and Mark Kelly to Please Stay Away.