Risk Management
In one of my first blog posts, I talked about risk. Any self-defense tactic or methodology you employ is a risk management decision. However, where we get our information around risk is often suspect. Many of the providers of this information have conflicts of interest. We must sort through a lot of information via good critical thinking, which usually requires background knowledge. Unfortunately, “background knowledge” has been called the dirty secret of critical thinking instruction. Even the appropriate amount of background knowledge is not enough. Critical thinkers also need to be “street-smart.” Money, power, prestige, and sex are powerful motivators for action and have existed since civilization began. You can see many of these influences in the book Empire of Pain (NYT Review), about the Sackler family and the drugs leading to Oxycontin.
With that background out of the way, I want to examine the CDC’s firearm violence page. Here are the questions about risk I highlighted in my first post.
- Who is responsible for determining risk?
- Who is responsible for conveying risk?
- What happens if there are mistakes in determining risk?
- What happens if risk is expressed misleadingly?
- Who benefits if mistakes are made?
- Who experiences the harms if mistakes are made?
- Are there other influences besides risk that may influence a person’s choice?
With this background in mind, let’s dive into the CDC’s webpage on firearm violence
The CDC’s Web Page – Fast Facts: Firearm Violence Prevention
Here is the CDC’s firearm violence prevention page. Based on the title, this page aims to list ways to prevent firearm violence. Since some background is necessary, they start with a definition.
What is a firearm injury?
A firearm injury is a gunshot wound or penetrating injury from a weapon that uses a powder charge to fire a projectile. Weapons that use a power charge include handguns, rifles, and shotguns. Injuries from air- and gas-powered guns, BB guns, and pellet guns are not considered firearm injuries as these types of guns do not use a powder charge to fire a projectile.
I don’t see anything too controversial about that definition. My only thought is that it implicitly defines what a firearm is. Next, the CDC lists the types of firearm injuries.
What are the different types of firearm injuries?
There are many types of firearm injuries, which can be fatal or nonfatal:
Intentionally self-inflicted
Includes firearm suicide or nonfatal self-harm injury from a firearm
Unintentional
Includes fatal or nonfatal firearm injuries that happen while someone is cleaning or playing with a firearm or other incidents of an accidental firing without evidence of intentional harm
Interpersonal violence
Includes firearm homicide or nonfatal assault injury from a firearm
Legal intervention
Includes firearm injuries inflicted by the police or other law enforcement agents acting in the line of duty
For example, firearm injuries that occur while arresting or attempting to arrest someone, maintaining order, or ensuring safety
The term legal intervention is a commonly used external cause of injury classification. It does not indicate the legality of the circumstances surrounding the death.
Undetermined intent
Includes firearm injuries where there is not enough information to determine whether the injury was intentionally self-inflicted, unintentional, the result of legal intervention, or from an act of interpersonal violence.
Let’s discuss these two sections.
Injuries: Fatal and Non-Fatal?
First, the CDC says that a firearm injury can be fatal or not fatal. That is rather odd, as you would usually speak of fatalities and injuries separately. Does the CDC combine injuries and fatalities into just injuries for anything else? Let’s look at other issues the CDC handles.
- https://www.cdc.gov/transportationsafety/ No. Separates fatalities from injuries.
- https://www.cdc.gov/drowning/index.html Only talks about fatalities.
- https://www.cdc.gov/falls/index.html No. Separates fatalities from injuries.
- https://www.cdc.gov/drugoverdose/deaths/index.html It only talks about fatalities. It does not speak about non-fatal overdoses.
- https://www.cdc.gov/suicide/ Separates fatalities from attempts. Most suicide attempts that do not succeed result in the person being placed in confinement for psychiatric evaluation, possibly for several days. If the suicide attempt did not result in a physical injury, I’m unsure whether the psychiatric evaluation allows it to be classified as injurious.
Oddly, the CDC appears to separate fatalities from injuries if you go through the webpage. However, based on the definition, they may combine them, which is a crucial point regarding the definition. Deaths in the United States are seriously investigated and documented. They are the gold standard for data. On the other hand, injury data is in its infancy regarding how the CDC gathers it. Mixing two very different data sources with different reliability could cause massive misunderstandings. As such, I recommend separating fatalities differently from injuries.
Firearm Deaths per Day
Let’s look at the next section:
How common are firearm injuries?
Firearm injuries are a serious public health problem. In 2020, there were 45,222 firearm-related deaths in the United States – that’s about 124 people dying from a firearm-related injury each day. More than half of firearm-related deaths were suicides and more than 4 out of every 10 were firearm homicides.
Here is the WONDER report from 2020 (the columns are number, population, and rate):
Accidental discharge of firearms (W32-W34) 535 329,484,123 0.2
Intentional self-harm (suicide) by discharge of firearms 24,292 329,484,123 7.4
Assault (homicide) by discharge of firearms (*U01.4,X93-X95) 19,384 329,484,123 5.9
#Legal intervention (Y35,Y89.0) 611 329,484,123 0.2
Discharge of firearms, undetermined intent (Y22-Y24) 400 329,484,123 0.1
The total is 45,222 (out of almost 329.5 million). There are two big areas the CDC mentions: Suicide and Assault. Let’s look at the percentages:
Suicide 24,292/45,222 = 54%
Assault: 19,384/45,222 = 43%
These two items make up 97% of the total.
The CDC also states, “that’s about 124 people dying from a firearm-related injury each day.” We want to try and establish context for numbers that appear out of the blue. Let’s look at the CDC’s mortality report for 2020 for all deaths.
https://www.cdc.gov/nchs/nvss/deaths.htm
Total Deaths: 3,383,729
Number of days in 2020: 366
3,383,729/366 = 9,245 deaths per day on average.
If we subtract firearm deaths (124) from the deaths per day average (9,245), we get 9,121 deaths per day. To calculate a percentage difference, we use the following formula:
Percentage Difference = (9121 – 9245)/9245 * 100
That is about a -1.3% difference. What happens if we subtract out suicide by firearm?
24,292 / 366 = 66
That would be 124 – 66 = 58. We say that 58 people die per day from assault with a firearm. So, we would say the total deaths per day minus the deaths per day from firearm assault would be:
9,245 – 58 = 9,187.
Which would be a -0.63% difference.
These differences do not seem large enough to denote a public health problem. Let’s look at the CDC data table for the top 10 causes of death in 2020.
https://www.cdc.gov/nchs/data/databriefs/db427-tables.pdf#4
We can all agree that COVID was considered a serious public health problem in 2020. COVID is number 3 in the top ten list. Let’s see what the deaths per day of COVID are:
350,831/366 = 959
This number is almost eight times higher than firearm deaths per day.
Non-Fatal Injuries, or rather, just Injuries
Let’s go to the next section on the CDC’s web page
More people suffer nonfatal firearm-related injuries than die. More than seven out of every 10 medically treated firearm injuries are from firearm-related assaults. Nearly 2 out of every 10 are from unintentional firearm injuries. There are few intentionally self-inflicted firearm-related injuries seen in hospital emergency departments. Most people who use a firearm in a suicide attempt, die from their injury.
Here the CDC indicates that unless you tried to commit suicide with a firearm, you are far more likely to be injured than killed. Of those non-fatally injured, not quite 20 percent are from accidents. A bit more than 70 percent is from “firearm-related assaults.” We are unclear if firearm-related assaults are criminal activity or justified (i.e., self-defense, law enforcement, etc.). Herein lies another problem: the CDC cannot distinguish between criminal activity with a firearm and non-criminal activity with a firearm. Although the CDC has a category of Legal Intervention, the definition states that the legality of circumstances is not determined.
The Top 5, Age Range 1-44
Let’s go to the next section:
Firearm injuries affect people in all stages of life. In 2020, firearm-related injuries were among the 5 leading causes of death for people ages 1-44 in the United States.
Dying aged 1-44 isn’t common; otherwise, life expectancy would not be very high. Here is the report from WONDER in 2020 for ages 1-44 (number, population, rate):
#Accidents (unintentional injuries) (V01-X59,Y85-Y86) 80,208 187,319,938 42.8
#Intentional self-harm (suicide) (*U03,X60-X84,Y87.0) 22,431 187,319,938 12.0
#Assault (homicide) (*U01-*U02,X85-Y09,Y87.1) 18,838 187,319,938 10.1
#Diseases of heart (I00-I09,I11,I13,I20-I51) 17,310 187,319,938 9.2
#Malignant neoplasms (C00-C97) 16,708 187,319,938 8.9
#COVID-19 (U07.1) 8,902 187,319,938 4.8
#Chronic liver disease and cirrhosis […] 6,620 187,319,938 3.5
#Diabetes mellitus (E10-E14) 4,445 187,319,938 2.4
#Cerebrovascular diseases (I60-I69) 2,927 187,319,938 1.6
#Influenza and pneumonia (J09-J18) 2,100 187,319,938 1.1
#Congenital malformations […] 2,031 187,319,938 1.1
#Chronic lower respiratory diseases (J40-J47) 1,579 187,319,938 0.8
#Septicemia (A40-A41) 1,549 187,319,938 0.8
#Human immunodeficiency virus (HIV) […] 1,291 187,319,938 0.7
For now, let’s talk just about Assault (I’ll discuss suicide later in the post, also, see my previous post on firearm suicide). The top 5 are accidents, suicides, assault, heart disease, and cancer. The assault rate (which includes all deaths by assault, not just firearms, but firearm use is very high) is slightly higher than “disease of the heart” or “malignant neoplasms” (cancer) for the age group of 1-44. These are hardly diseases you associate with this age group, yet they are in the top 5. Accidents were four times more likely to kill a 1–44-year-old than assaults. Be aware that accidents, as they are defined, include drug overdoses. In short, you could have a “top 5” causes of death for any age group. It doesn’t mean that they are common or concerning. If heart disease and cancer are not “public health problems” for the 1-44 age group, one must scratch their head to determine why assault is.
Race, Ethnicity, and Age
Let’s check the next section:
Some groups have higher rates of firearm injury than others. Men account for 86% of all victims of firearm death and 87% of nonfatal firearm injuries. Rates of firearm violence also vary by age and race/ethnicity. Firearm homicide rates are highest among teens and young adults 15-34 years of age and among Black or African American, American Indian or Alaska Native, and Hispanic or Latino populations. Firearm suicide rates are highest among adults 75 years of age and older and among American Indian or Alaska Native and non-Hispanic white populations.
Essentially, we are already dealing with a small population, and the CDC narrows it down even more:
- Men, just like in violent crime, are implicated.
- Young adults 15-34. As an aside, when does someone become an adult as opposed to a young adult?
- For a long time, crime researchers have known that homicides are usually within groups – I.e., whites kill whites, and blacks kill blacks.
- Firearm suicide rates are highest in adults 75 years of age and older. The rate may be relatively high, but the population isn’t large due to the life expectancy in those groups based on the race and ethnicity highlighted by the CDC. See the CDC’s table here: https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-01.pdf. These are likely people dealing with problems due to age, such as terminal disease or being severely crippled, and are likely past their average life expectancy for their race and ethnicity.
DGUs (again)
Let’s go to the most interesting section in the firearm violence prevention section:
What is defensive gun use? How often does it occur?
Although definitions of defensive gun use vary, it is generally defined as the use of a firearm to protect and defend oneself, family, other people, and/or property against crime or victimization.
Estimates of defensive gun use vary depending on the questions asked, populations studied, timeframe, and other factors related to study design. Given the wide variability in estimates, additional research is necessary to understand defensive gun use prevalence, frequency, circumstances, and outcomes.
I covered the CDC and DGUs in a previous post, but there is one aspect I want to cover here. I’ll quote from the article at https://thereload.com/emails-cdc-removed-defensive-gun-use-stats-after-gun-control-advocates-pressured-officials-in-private-meeting/
Gary Kleck: “You can’t understand any significant aspects of the gun-control debate once you eliminate defensive gun use,” he said. “It becomes inexplicable why so many Americans oppose otherwise perfectly reasonable gun-control measurements. It’s because they think it’s gonna lead to prohibition, and they won’t have a gun for self-defense. It’s not complicated.”
Herein lies a problem. Let’s say all your measures of success are around firearm injuries. If the CDC convinces Americans that firearm violence is a public health problem, new firearm regulations will be passed. These regulations result in a decline in DGUs because American citizens cannot procure firearms for self-defense. However, the CDC’s measure of success is the number of firearm injuries. If firearm injuries decline, then the regulations that were implemented are successful. However, from my book, we know that most injurious violent crime doesn’t involve firearms, so a victim armed with a firearm can defend themselves, usually without discharging it. But, they can become victimized if they can no longer wield the intimidating firearm. Since the offenders don’t usually use firearms in injurious violent crimes, there is no increase in firearm injury statistics. In short, injurious violent crime victimization would increase, but the CDC wouldn’t see it.
This problem is no different than the Federal government believing that alcohol Prohibition was successful because their only measure of success would be the reduction of alcohol consumption. Gang wars do not count against the “success” of Prohibition.
Firearm Violence and Safe Storage
The CDC has a section on the consequences of firearm violence, which I discuss in the book extensively, so I won’t repeat it here. The rest of the web page is not specific to firearm statistics. The CDC does mention, toward the end, the safe storage of firearms. But, again, I cover this in far more detail in my book than the CDC, so I’ll skip it here.
Evaluating the CDC Firearm Violence Prevention Page
Definitions matter
There are several problems with the CDC’s page. I’ll go through them one by one.
- “Firearm Violence” is never defined.
- Firearm injuries are set up to be combined with fatalities.
- Firearm injuries are divorced from intent.
- Firearm injury tabulations are the only measure of success.
For many Americans, the everyday use of the word violence implies criminal intent. Let’s go through some examples to see what I mean. You are having a friendly conversation with your neighbor across the street in all these examples.
- He says: “Drug violence is getting out of hand. My uncle went home and deliberately overdosed on his prescription medication.”
- He says: “Vehicle violence is getting out of hand. My uncle was driving, turned the wrong way down a one-way road, and got into an accident.”
- He says: “Gun violence is getting out of hand. My uncle is a law enforcement officer and had to shoot a knife-armed domestic abuser yesterday.”
I doubt whether you find your neighbor’s comments intuitive. What is worrisome is that, based on the CDC’s web page, the implied definition of firearm violence is:
Firearm violence is defined by the total amount of firearm injuries (fatal and non-fatal) divorced from intent. Therefore, successful prevention of firearm violence involves the reduction of firearm injuries.
If you care about the ability to defend yourself, my speculation on the CDC’s firearm violence definition should send chills down your spine.
Suicide
The most significant contributor to firearm violence is suicide by firearm. In 2020, 55 percent of firearm violence, as the CDC defines it, is suicide by firearm. This percentage leads to the question: What is the suicide prevention working group of the CDC working on that is different than what the firearm violence CDC working group is tasked with solving? After all, if you had a problem and could solve 55 percent of it, you would be thrilled. But let’s discuss what this means. If the CDC implemented changes to somehow limit firearm access to suicidal individuals, but those individuals chose to commit suicide with something other than a firearm, firearm suicides would drop by 55 percent. Still, the number of people who committed suicide would remain the same. Is that success? I would say no.
Let’s reformulate this idea: A successful prevention program for firearm suicides would reduce the total number of firearm suicides AND correspondingly reduce the total number of suicides by the same amount every year OVER the course of a decade.
For example, assume there were 50,000 suicides one year, and out of that 50,000, there were 25,000 firearm suicides. As a result, a prevention program for firearm suicides was implemented, and it took a year to implement. To keep things simple, let’s assume a constant population over ten years. Here is the result over ten years:
- Prevention Plan: Total suicides, 455,000; suicide by firearm, 205,000.
- Expected If No Prevention Plan: Total suicides, 500,000; suicide by firearm, 250,000.
If you care about public health and suicides, you will use this definition of success. For example, if you simply count firearm suicides, you could have the following result and claim success:
- Prevention Plan: Total suicides, 500,000; suicide by firearm, 205,000.
- Expected If No Prevention Plan: Total suicides, 500,000; suicide by firearm, 250,000.
Here, it appears that suicide by firearm was reduced. However, what happened is the suicidal individuals took their life another way. Therefore, if you care about public health and suicides, you must use the first way of defining success.
Assault with a Firearm
The next big target would be firearm assaults. The methodology of how the CDC quantifies firearm violence should be evaluated on how it could solve known historical problems with known historical solutions. Suppose you took the CDC’s methodology and applied it to alcohol Prohibition in America. Would the CDC’s approach figure out that banning the legal purchase of alcohol was the cause of firearm injuries in that period due to gang-related activity around the buying, selling, and distribution of illegal alcohol? Clearly not, because the CDC doesn’t distinguish firearm injuries due to criminal activity from other forms of firearm injury. The inability to distinguish these two means it cannot detect a motive for criminal firearm injuries. If your methodology cannot solve known historical problems with known historical solutions, you have problems with your methods. Let’s fast forward to today. Once you factor out suicides with a firearm, a strong case could be made those firearm injuries are primarily due to criminal activity, which is motivated by illegal drug addiction and the business of buying, selling, and distributing illegal drugs. But, again, this fact cannot be ascertained via the CDC’s methodology.
There is an additional problem with non-fatal firearm injuries. As most emergency rooms are required to report a firearm injury to law enforcement, the report law enforcement makes of this injury will not be from the crime scene. It is entirely dependent on the truthfulness of the injured. If the injured engaged in criminal activity, they probably wouldn’t be forthcoming to law enforcement. In short, criminal activity will likely be hidden as a source of non-fatal firearm injuries, just as it is in how the CDC tabulates firearm fatalities.
What about firearm injuries that are the result of self-defense? If the CDC counts DGUs, how many DGUs will be associated with firearm injuries and fatalities in the future? Currently, the firearm injury category of Legal Intervention only mentions law enforcement. The UCR already has a justified homicide statistic for private citizens, which is probably undercounted (see my book). Whether or not the CDC will incorporate those DGUs that result in non-fatal firearm injuries remains to be seen. However, we can see that the CDC includes law enforcement’s use of lethal force as a firearm injury. I suspect they would do the same for civilians too. Therefore, a possibility exists that the CDC will count DGU injuries, add those to the total of firearm injuries, and show an increase in firearm violence! That would be like adding up all the people successfully treating a medical condition with prescription medication and including that number as part of drug violence! Hopefully, that will never happen, but you can see the problems arising when you divorce intent from your measure.
Risk Part II
Let’s look at the risk questions that I enumerated at the beginning:
- Who is responsible for determining risk? Who is responsible for conveying risk? Do the entities responsible for determining or conveying risk have any conflicts of interest or pre-existing biases that would prevent a fair and honest risk assessment?
Since the CDC has declared firearm violence a public health threat, they seem to determine firearm violence risk and convey it. The next question is about pre-existing biases or conflicts of interest. A series of posts (Part 1, Part 2, Part 3) from Timothy Wheeler, MD, asks whether the CDC can give a fair and honest assessment of firearms.
- What happens if there are mistakes in determining risk? What happens if risk is expressed misleadingly?
These two questions are very similar in the CDC and firearm violence prevention case. The CDC’s approach allows ordinary civilians to error around their risk of firearm violence fundamentally. Part I of my book showed that injurious violent crime rarely involves firearms. I believe that criminal activity is present in many non-suicidal firearm fatalities and non-suicidal firearm injuries, primarily due to the number of “relationship unknowns” as the victim/offender relationship. Thus, to put it bluntly, let’s reword what firearm violence seems to be: “Firearm violence is a public health threat primarily for those who are suicidal and those who are engaged in criminal activity, particularly around the buying, selling, and distribution of illegal drugs.” In short, civilians have much to worry about other than firearm violence (e.g., opioid addiction, falling, traffic fatalities and injuries, etc.).
- Who benefits if mistakes are made regarding risk? These could be mistakes in the analysis, messaging, or the background biases that formed the original investigation.
This is a good question without a clear answer. We can speculate that the CDC developed a solution and then, based on the solution, created the methodology that would point to that solution. Unfortunately, that solution seems to be enabling federal government firearm regulation due to a public health threat. In short, the CDC appears to be a politicized organization not working in the public’s best interest.
How do you provide support for federal firearm regulation via public health? Well, you gather as many “firearms are bad” statistics as you can (and keep them general), and you do not talk about any “firearms are good” statistics like DGUs. Furthermore, you keep everyone in the dark about how most injurious violent crime doesn’t involve firearms. Up to this point, the CDC never mentions violent crime, the Uniform Crime Reports, or the National Crime Victimization Survey on their webpage. Shouldn’t you include something around violent crime if your page is about firearm violence prevention?
Unfortunately, it gets worse. We have seen how the Federal government worked with Big Tech to suppress critics of the CDC’s COVID policy. Worse, the CDC promoted bad studies that showed that Non-Pharmaceutical Interventions (NPIs) worked. In 2023, we have now seen a meta-analysis that shows that there was no proof that masks worked (NOTE: if you want to initiate a policy that can cause bacterial infections and hurt the learning and emotional experience of children (just to name a few), you should have a quality study that shows that policy works. The burden is on the designers and implementers of that policy to provide a quality study that proves it. It is not the burden of the people to disprove it before implementation). Also, we have clear data from other parts of the world that school closures were unnecessary. Sadly, we now have the Federal government stating things as true in 2023 that people were getting censored from social media in 2020 for saying.
Ultimately, the question will be: what happens to critics of the CDC’s firearm violence prevention program? Will they be heard? Or will they be censored? Unfortunately, based on the changes in the DGU section of this webpage and the Freedom of Information Act requests, censorship appears to be still in play.
- Who experiences the harms if mistakes are made?
Ironically, the public is precisely who the CDC should be helping, yet the public would be experiencing any harms. Federal firearm regulations will do a lot to take weapons out of the hands of civilians but not out of the hands of criminals. These regulations could significantly reduce DGUs and likely lead to a significant increase in non-firearm violent crime victimization. Furthermore, the more criminals know that civilians aren’t armed, the more likely violent victimizations will be.
- Are there other influences besides risk that may influence a person’s choice?
Virtue signaling and conformance were amazing to me in the COVID era. I recognized social media was a force, but I ultimately did not expect its mindshare. Although there was substantial evidence compiled over a hundred years against the use of masks to protect against a respiratory virus, everyone felt compelled to wear them. If you didn’t wear them, you were being selfish and killing the elderly. Sadly, the number of vulnerable people who genuinely believed their masks protected them, went out and interacted with people in enclosed environments, and then died of COVID is horrific. Let me repeat: The number of vulnerable people the CDC killed with its mask guidance is horrific. These are people the CDC should be protecting, not jeopardizing. Secondly, lockdowns of the non-vulnerable and social distancing in an enclosed area were again quite silly against a respiratory virus. However, if you did not support them, you were socially shamed. Only after two years is the mainstream media beginning to report the ineffectiveness of these NPIs. We haven’t even gotten to vax shaming yet; probably the worst social shaming in recent history. It isn’t just shaming as many companies and government agencies mandated vaccinations of a vaccine that wasn’t tested to the level of all other effective historical vaccines. People lost their livelihoods. With Elon Musk’s release of the Twitter files, we finally understand how much the Federal government was doing to censor debate and shame critics on social media. Progress in public health requires fair debate, not censorship.