Episode 1 - ft. Anupam B. Jena, MD, PhD

LJ: You’re listening to “Leading Voices in Health Care Policy”, a podcast brought to you by the department of health care policy at Harvard Medical School. I’m Lauren Jett. Today we’re speaking with Ruth L. Newhouse associate professor of health care policy at Harvard Medical School, and physician in the Department of Medicine at Massachusetts General Hospital, Anupam B. Jena. Thank you, Dr. Jena, for speaking with us today.

AJ: Thanks for having me.

LJ: Recently you published a letter in the New England Journal of Medicine stating that gun-related injuries decrease during NRA conventions. Your letter points out that it’s often said that firearm injuries occur primarily among inexperienced users. But the study you conducted suggests otherwise. What exactly did you look at when conducting this study?

AJ: We looked at data from a very large insurance database, tens of millions of visits to doctors, to emergency departments, to hospitals during the dates of annual National Rifle Association Conventions. These happen three to four days per year, they happen every year. And the idea was the following, was that if enough people attend these conventions who are firearm users and if there’s enough venues where firearms are typically used that are closed during this time because owners of these venues might go to these conventions, could we expect to see a reduction in firearm injuries during those very specific dates simply because there’s a reduction in firearm use? And, if we were to see that, then that might then suggest that using a firearm has an inherent risk to it, even among people who are presumably very experienced firearm users. So that was the study idea.

LJ: So, who usually attends NRA conventions? Does this coincide with the population of where you saw the biggest decrease of gun-related injuries during those times?

AJ: Good question. So, the NRA conventions attract about 80,000 people each year. I don’t know that everybody who goes there is a gun owner, but it might be families of gun owners as well, but that’s about the size we’re talking about, about 80,000 people per year. The NRA itself says it has about 5 million members, and it’s important to note that the number of people who go to the convention is a very small proportion of people that own guns in the United Sates. And it’s also a relatively modest proportion of people who belong to the NRA. So the question that you might ask is “well, how was it possible if, let’s say, 1% of gun owners go to a meeting, that we observe almost a 20% of reduction of gun injuries during those dates?” That’s a challenging question to answer. My instinct would be that the individuals who attend the conventions are disproportionally heavy users of firearms compared to the general gun owning population. And what I mean by that is it could certainly be the case that the typical gun owner in this country just owns a firearm and they keep it in the house under lock and key, but not use it. But, the distribution of gun owners and the distribution of gun use is probably very skewed, which means there’s a small portion of people who own a lot of firearms and use firearms quite a bit.  If that’s true, then it’s possible that even the small reduction of utilization by those people may lead to observed decline in firearm injury rates. In terms or whether or not our findings coincided with the population of where we saw the biggest decrease of firearms injuries, I think so. One of our hypotheses would be that reduction should primarily be seen among men. And why is that? It’s because men are more likely to own and operate firearms, and at conventions themselves, the population of men is about 80% of the whole convention population. And so we do find larger decreases in gun injuries among men. The other place where we find larger decreases is in areas of the United States where gun ownership is higher, which makes sense. If individuals in those states where gun ownership is high are more likely to attend the convention and they’re more likely to use firearms, then we’d expect larger reduction of firearm injuries in those areas, and that’s exactly what we find. And then the last prediction is that someone is probably more likely to go to a convention when they live closer to it. So if you live in New Hampshire you’ll less likely go to a convention across the country than if it’s, you know, on the east coast somewhere.  And what we find is that the reduction in gun injuries is larger when the convention is held closer to you in any given year. So I think that all of those findings are consistent with the hypotheses that we raised.

LJ: How many gun-related accidents are usually seen in the emergency room on a normal day?

AJ: Hard to say, the best available statistics from the CDC is that there’s about 5 unintentional gun related injuries per 100,000 people in the United States, so I think that’d be about the rate you’d expect to see per day. It’s worth noting that that rate is much lower than the rate of intentional gun injuries. So these would be related to assault or homicide or suicide- those rates are higher than the rates that you’d observe for unintentional injuries. But I think the best way for me to characterize this is in a given year, what proportion of Americans experience an unintentional gun related injury, and that’s about 5 per 100,000.

LJ: You touched on this a little bit earlier, but how much does this rate of gun related accidents decrease in the emergency room during NRA conventions?

AJ: We found about a 20% reduction in this rate during NRA conventions. That’s a large decrease and some of the debate over our article was how could it be so large when only a small proportion of gun owners attend these conventions. For that I have a few answers. The first is that the people who attend these conventions are probably disproportionally heavy gun users, and so taking a 1% of this group is probably very different than taking a random 1% of gun users. So that’s part of the explanation. The other part is that if owners of venues were firearms are used are attending these conventions we might observe that there would be reductions in firearm injuries not only among NRA members, but also people that aren’t part of the NRA who would happen to be less likely to use firearms during those few days when the conventions are held. Anecdotally, we’ve heard that. The last thing that’s important to know is that although we find a 20% decrease in the rate of gun injuries during NRA conventions, it’s important to recognize that that 20% number is only an estimate and there’s a large confidence interval around it, which means that the certainty of whether or not this is 20% or 5%- we can’t make that distinction, but we can say that it’s not zero.

LJ: Did all gun related incidents, such as crimes involving firearms, decrease during the conventions?

AJ: Good question. So we primarily found that there were reductions in what we think are unintentional injuries, and the reason we think that is because the population that we looked at is a privately insured population. And so, assuming that these individuals are not committing many crimes, and what we’re identifying are probably unintentional injuries due to firearms that are being reduced during these dates. We did look at a different database of crimes in the United States, and didn’t find any reduction in crimes.

LJ: The NRA speaks to gun safety and education, yet gun-related injuries decrease during their conventions, when their members aren’t out hunting or at gun ranges, or generally using their guns. So, what’s going on?

AJ: Yeah, I mean it’s an open question I think. This is an interesting idea that there was a meaningful reduction in gun injuries during the dates of these conventions, and that suggests that at least the possibility that a transient reduction in gun use can lead to a reduction in gun injuries. In some sense that may be obvious, if you adopt a view that owning and operating a firearm entails some positive risk, then if you don’t operate the firearm you should reduce your risk of injury. I would liken this to driving a car. Even for the most experience driver, there’s always a risk once you get behind a wheel, and driving a car is inherently more safe than walking around in circles in your apartment or your office. You always run some risk.

LJ: Thank you so much, Dr. Jena, for joining us today and for your insight on why gun-related injuries decrease during the NRA Conventions.

AJ:  Thank you

LJ: You can read Dr. Jena’s letter to the New England Journal of Medicine on their website, at NEJM.org. That’s all for this episode of Leading Voices in Health Care Policy. From the department of health care policy at Harvard Medical School, I’m Lauren Jett. For more of the top news and updates on health care policy, be sure to follow us on twitter at HCPHMS and check out our website at hcp.med.harvard.edu