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Medical News & Perspectives
April 26, 2016

Tale of 2 Agencies: CDC Avoids Gun Violence Research But NIH Funds It

JAMA. 2016;315(16):1689-1692. doi:10.1001/jama.2016.1707

Garen Wintemute, MD, MPH, is the first to describe his lifestyle as frugal. An emergency room physician on the faculty of the University of California, Davis, Wintemute lives in a $900-a-month 1-bedroom apartment on the outskirts of Sacramento. He has no children, so he doesn’t have to sock away a chunk of his salary toward college tuition. “There’s a fair amount of money left over every year,” he said.

So much so that the 64-year-old Wintemute has already donated $1.3 million of the $2 million he has pledged toward the UC Davis Violence Prevention Research Program, which he happens to direct. Without his contribution, “we probably would have disbanded,” Wintemute said, noting that at one time he was the program’s main source of money.

Such financial woes can be attributed in part to the fact that the US Centers for Disease Control and Prevention (CDC) hasn’t funded research into gun violence prevention for 2 decades, ever since Congress included these 3 lines—named the Dickey Amendment for then-representative Jay Dickey (R, Ark), who introduced it—on page 245 of the 750-page Omnibus Consolidated Appropriations Act of 1997: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” (http://1.usa.gov/22zCqKD) The amendment was in response to a CDC-funded study that concluded having a gun in the home was associated with a higher risk of homicide by a family member or intimate acquaintance (Kellerman AL et al. N Engl J Med. 1993:329[15]:1084-1091).

Since the Consolidated Appropriations Act of 2012, the same language has also applied to the National Institutes of Health (NIH). However, as part of a funding opportunity for violence research announced in 2013, the NIH awarded Wintemute a total of about $850 000, from May 2015 through April 2017, to study whether gun owners with a history of alcohol and drug convictions are more likely to commit violence than gun owners without such a criminal history (http://1.usa.gov/1Vn5GiB).

Why the 2 federal agencies have interpreted the same rider so differently is not clear. Critics say the CDC has overreacted to the amendment’s vague language. But other observers note that the size of the NIH budget gives it less reason to be concerned about retaliation by pro-gun members of Congress. For the current fiscal year, the NIH budget is $32.3 billion, compared with the CDC’s $11.8 billion ($4.5 billion of which is earmarked for mandatory programs such as Vaccines for Children). Officials at the CDC and NIH declined to comment on agency policies regarding gun violence prevention research.

“What people don’t understand is there’s no federal ban on research,” said Mark Rosenberg, MD, MPP, a 20-year CDC veteran who says he was fired as director of the National Center for Injury Prevention and Control in 1999 because of his commitment to studying gun violence prevention. “But the leaders of CDC are scared to take this on because it’s so politically controversial.”

David Satcher, MD, PhD, a former surgeon general who now directs the Satcher Health Leadership Institute at the Morehouse School of Medicine, was CDC director when Congress first tacked on the Dickey Amendment to the 1997 budget bill. “I’m not prepared to judge the people at the CDC,” Satcher said. “They don’t want to get into this [gun violence prevention research] unless they know someone has their back.”

Mary Woolley, president of Research!America, a nonprofit organization that advocates for increased funding for government agencies involved in scientific research, says she understands why the CDC might fear retribution from Congress if it resumed research into the roots of gun violence. “The CDC is funded in a different way than the NIH,” Woolley said. “They have line-item budgeting.” The NIH, on the other hand, has had more latitude in deciding what it wants to study, she said.

Window Dressing or Curtains Parting?

The CDC doesn’t completely ignore the issue of gun violence. In 2002, it created the National Violent Death Reporting System (NVDRS), which covers all types of violent deaths, including homicides and suicides committed with firearms. However, the NVDRS collects data from only 32 states.

“That’s about as benign as you can get,” Stephen Teret, JD, director of the Center for Law and the Public’s Health at the Johns Hopkins Bloomberg School of Public Health, said of the NVDRS. “It’s not only about guns, it’s about violence, and it’s just data collection.” The NVDRS could be used as a tool in gun violence research, Wintemute said, but “most of us see it as not research in itself.”

In December, the Senate passed by unanimous consent the Mental Health Awareness and Improvement Act, which, among many other things, “encourages” the secretary of Health and Human Services, through the CDC director, “to improve, particularly through the inclusion of additional states,” the NVDRS. However, “participation in the system by the states shall be voluntary,” according to the bill (http://1.usa.gov/1QjPwSM).

Unlike with other measures it proposes, the legislation doesn’t mention how it would fund an expanded NVDRS. According to the Congressional Budget Office, adding the remaining states and the District of Columbia would cost an estimated $12 million from 2016 through 2020 (http://1.usa.gov/1LrTbg6).

“It’s hard to know if this would mean that, yes, firearm research is coming back, or if it’s just window dressing,” Sandro Galea, MD, DrPH, said of the legislation’s intention to expand the NVDRS.

“The challenge to CDC is simple: is there new money for this work?” said Galea, dean of the Boston University School of Public Health. “If there isn’t, then it’s really hard to see them devoting much money to firearms. It’s hard for me to see a bill with substantial new resources for firearms to pass in this current political climate.”

Dickey, who left Congress in 2000, says he regrets his amendment’s unintended chilling effect on gun violence research. On December 25, 2015, he and Rosenberg coauthored an op-ed piece in the Washington Post, “How to protect gun rights while reducing the toll of gun violence.” (http://wapo.st/1MzGY8g) Like Dickey, Rosenberg, who says he owns a pellet air rifle to shoot squirrels and targets, is a member of the National Rifle Association (NRA).

“Both of us now believe strongly that federal funding for research into gun-violence prevention should be dramatically increased,” wrote Dickey and Rosenberg, now president and chief executive officer of the Task Force for Global Health, a nonprofit public health organization. But, they added, the language accompanying this appropriation should mirror the 1996 Dickey Amendment in that research aimed at restricting access to firearms by law-abiding gun owners be excluded from federal funding.

The op-ed piece echoed a letter Dickey had sent earlier in December to Rep Mike Thompson (D, Calif), chair of the House Gun Violence Prevention Task Force. “Research could have been continued on gun violence without infringing on the rights of gun owners,” Dickey wrote (http://1.usa.gov/1NHBW0A). “Doing nothing is no longer an acceptable solution.”

President’s Orders

After 20 children and 6 adults were murdered in December 2012 at Sandy Hook Elementary School in Newtown, Connecticut, President Obama called on Congress a month later to appropriate $10 million to CDC for gun violence prevention research (http://1.usa.gov/1JFGZGN). He directed the agency to immediately begin “assessing existing strategies for preventing gun violence and identifying the most pressing research questions, with the greatest potential public health impact.”

“Research on gun violence is not advocacy; it is critical public health research that gives all Americans information they need,” Obama said.

In a January 2013 memorandum, Obama ordered that “the secretary of Health and Human Services, through the director of the Centers for Disease Control and Prevention and other scientific agencies within the Department of Health and Human Services, shall conduct or sponsor research into the causes of gun violence and the ways to prevent it.” (http://1.usa.gov/1Q6aOto)

And yet, the Dickey Amendment remains in the yearly budget bill, including the one Obama signed in December, and Congress still hasn’t earmarked any money for gun violence research at the CDC.

The Dickey Amendment “has prohibited experts at the CDC from researching the causes of and best ways to prevent gun violence for nearly 20 years,” Thompson, a gun owner himself, said in a statement to JAMA. “The omnibus bill (signed by Obama in December) gave us a chance to fix that, but once again, Republicans refused to simply get out of the way and let our experts do what they do best—conduct research that will save some lives.”

But in an opinion piece for Politico in December, Chris W. Cox, the executive director of the National Rifle Association Institute for Legislative Action questioned the motives of those calling for Congress to restore CDC funds for gun violence research (http://politi.co/1IEHTcu).

“Anti-gun advocates in Congress are looking for creative methods to change public opinion. What better way than under the auspices of science?” Cox wrote. “Now, they just need some government-sponsored, taxpayer-funded data points to validate their anti-gun agenda.”

The Dickey Amendment does not oppose funding research into gun violence, he wrote. “Instead, it forbids funding for research meant to drive the political gun control agenda.”

The NRA “is not opposed to research that would encourage the safe and responsible use of firearms and reduce the numbers of firearm-related deaths,” Cox wrote.

NIH Forges Ahead

Although Congress has deemed since 2012 that no NIH funds can be used “to advocate or promote gun control,” that agency in 2013 announced a funding opportunity for research examining violence, in particular firearm violence (http://1.usa.gov/1Q3PK6A).

An NIH news release said the agency “developed this call for proposals in response to the Presidential memorandum in January 2013 directing science agencies within the US Department of Health and Human Services to fund research into the causes of firearm violence and ways to prevent it.” (http://1.usa.gov/1Xe5B24)

The NIH has funded 9 proposals, although only 2 specifically address firearms. Besides Wintemute’s, the other was submitted by Rina Eiden, PhD, a substance abuse researcher at the University of Buffalo.

Eiden received $723 000 in fiscal year 2015 to study the precursors of gun violence, such as gang involvement and weapon carrying, in a cohort of 218 children aged 11 to 14 years, whom she had recruited at birth for a separate study of developmental problems linked to prenatal cocaine exposure.

The project is her first foray into gun violence research; she had not previously had a funding opportunity to study the topic, Eiden said.

“Ultimately, funding drives science, to a certain extent,” Eiden said. “It’s hard to blame the CDC when they’re so dependent on funding. They really have to pick and choose their battles.”

“Crazy to Not Find Out What Works”

Linda Degutis, DrPH, MSN, said frustration over the lack of funding for gun violence prevention research was “one of the many reasons” she left the CDC in 2014 after 3 years as director of the National Center for Injury Prevention and Control.

She now works part-time for the Henry M. Jackson Foundation for the Advancement of Military Medicine and volunteers with the Avielle Foundation, created by the parents of 6-year-old Avielle Richman, who was murdered at Sandy Hook. The foundation funds “research exploring the underpinnings of the brain that lead to violent behaviors and to foster the engagement of communities to apply these insights.” (http://bit.ly/1mnQcyH)

“I’m not as optimistic about CDC as I am perhaps about other federal agencies or private foundations doing some of the funding,” said Degutis, a past president of the American Public Health Association who was on the faculty at Yale before working at the CDC. “It seems so crazy to not find out what works [to reduce gun violence].”

Teret, who previously directed Johns Hopkins’ Center for Gun Policy and Research and its Center for Injury Research and Policy, believes the CDC is “being overly fearful and misinterpreting what Congress told it many years ago.” From the beginning, CDC worried that Congress might perceive any type of gun violence research as a violation of the Dickey Amendment, said Teret, adding that funding for his current research into designing safer guns comes mainly from private individuals.

“I don’t think CDC has ever been seen as being politically adventurous or courageous,” he said. “Even in the absence of an additional $10 million, CDC could have said, ‘Let’s reallocate some of our spending.’”

Meanwhile, at least 1 city and 1 state are looking to pick up the slack. Seattle began taxing guns and ammunition on January 1, 2016, to fund firearm violence prevention programs and research (http://bit.ly/1PWhEOU), and a California state lawmaker introduced a bill in February that would establish a firearm violence research center at the University of California. “I hope my colleagues in Congress will find the courage to follow California’s lead and permit federal funding for gun violence research,” Sen Dianne Feinstein (D, Calif) said in a statement (http://bit.ly/1V6FR6k).

Hanifa Shabazz, a councilwoman in Wilmington, Delaware, a state that is not part of the NVDRS, said she was surprised to learn that the CDC was not funding research into gun violence prevention. Last year, the CDC agreed to Shabazz’s request to investigate why her small city has one of the highest murder rates in the country.

The agency sent a team of Epidemic Intelligence Service officers to Wilmington, and they submitted their final report to the Delaware Department of Health and Social Services, which released it in November. However, the report makes no mention of what types of guns are used in Wilmington homicides and how perpetrators obtained them (http://1.usa.gov/1o05R93).

“People are dying [as a result of firearms], 90 or so a day on average,” Wintemute noted. “It must gall CDC a great deal not to be in the game.”

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