chapter 6
GUNS—INJURIES AND FATALITIES

Firearm-related incidents are a leading cause of preventable injury and death, particularly among young people. Doctors Against Handgun Injury, a coalition of twelve clinical and professional medical societies, calls handgun injuries a public health problem, a political issue, and a criminal justice concern. The group contends: "While we have enough data in the area of firearm injuries to know there is a problem, we do not have enough detailed information to fully understand its dimensions or properly evaluate efforts to ameliorate it."

The public health establishment, represented at the national level by the Centers for Disease Control and Prevention (CDC), believes that collecting comprehensive data on firearms injuries and deaths—such as who was shot, under what circumstances, and with what kind of weapon—is the first step in reducing those injuries and deaths. The next step, they believe, may be a campaign like those that eradicated polio and reduced traffic fatalities. The HELP Network, an international coalition of medical, public health, and allied organizations, described the form such a campaign might take ("The Public Health Approach to Firearm Injury Prevention," http://www.helpnetwork.org/frames/resources_factsheets_pubhealth.pdf [accessed September 23, 2004]):

Most firearm deaths in the U.S. are caused by handguns, yet handguns account for a minority of all firearms owned. The handgun can be recognized as a high-risk weapon, and perhaps even as the primary agent of the modern epidemic of gun death. One strategy to reduce these risks may be to restrict civilian access to certain kinds of handguns.

The CDC, in collaboration with the U.S. Product Safety Commission, administers the only national system that tracks firearm-related injuries—the National Electronic Injury Surveillance System (NEISS). Established in 1992, NEISS as of 2004 had collected data from ninety-one participating hospital emergency departments. Expansion of the surveillance system beyond the ninety-one hospitals is a CDC goal and is being researched.

State and local health departments report that they lack the funding to conduct a thorough surveillance of firearms injuries. To investigate how many health agencies conduct surveillance, Roger Hayes and colleagues carried out a survey of all fifty state health departments, as well as the city and county health departments of the fifty largest urban areas. The report is titled Missing in Action: Health Agencies Lack Critical Data Needed for Firearm Injury Prevention (Chicago: The HELP Network, 1999). The survey reports that thirty-one states (62%) maintain some type of firearm injury surveillance, but nineteen (38%) do not. More than one-half of the states (56%) track mortality data, 30% track hospital data, and 38% track the type of firearm. Twenty-six percent of the states track circumstances. Only 18% issue a report. According to the HELP report, the lack of funding and staffing were the main obstacles to adequate surveillance.

According to the survey, about one-half of the city and county health departments collected data on firearm injuries and deaths. Less than one-quarter collected information on firearm types involved in injuries or on the circumstances, and 35% issued a report. The lack of funding and staffing were the reasons cited by health departments for not collecting data.

Concerned about the lack of firearms injury data, the CDC in September 2002 awarded $7.5 million to six states (New Jersey, Maryland, Massachusetts, Oregon, South Carolina, and Virginia) to develop the nation's first comprehensive system for collecting data about violent deaths, the National Violent Death Reporting System. In 2004 the U.S. Congress granted $3.7 million to continue implementing the system. The CDC has identified four main objectives for the system:

• To link records from violent deaths that occurred in the same incident to help identify risk factors for multiple homicides or homicide-suicides;

TABLE 6.1

• To provide timely information through faster data retrieval. Currently, vital statistics data are not available until two years after the death;
• To describe, in some detail, the circumstances that might have contributed to the violent death; and
• To better characterize perpetrators, including their relationship to the victim(s).

The CDC aims to "illustrate a more comprehensive picture of violent incidents" in order to provide useful information to law enforcement personnel and death investigators in local areas. They hope to have all fifty states as part of the program within ten years. When data is released in 2005, more will be known about factors such as the involvement of alcohol or drugs in violent deaths, the type and source of the weapons used, and whether social-service agencies or the police had prior warning of domestic violence or child abuse.

WHAT IS KNOWN ABOUT FIREARMS INJURIES?

Data on gunshot injuries and firearm-related deaths for the period 1993 to 1997 were collected from victim surveys, hospital emergency room surveillance, and government entities such as the National Center for Health Statistics (death certificates), the Federal Bureau of Investigation (FBI) (reported homicides), and the CDC (firearms injury studies) for the report Firearm Injury and Death from Crime, 1993–97 (U.S. Department of Justice, Bureau of Justice Statistics, Selected Findings, October 2000). The authors noted that efforts to count injuries were complicated by limitations such as the failure of some sources to provide data on victims who later died, or the inability of other sources to make estimates because of too few cases reported. The authors estimated that there were 19.2 million incidents of nonfatal violent crime committed from 1993 through 1997, excluding simple assault. Table 6.1 presents some of the data from the report. The following are highlights:

• Of serious nonfatal violent victimizations, 28% were committed with a firearm, 4% resulted in serious injury, and 1% resulted in gunshot wounds.
• Assault accounted for 62% of the 411,800 nonfatal firearm-related injuries treated in emergency departments. (See Table 6.1.) Of 180,533 firearm-related fatalities, 44% were homicides and 51% were suicides.
• Gunshot wounds from assaults treated in emergency departments fell by 39%, from 64,100 in 1993 to 39,400 in 1997. (See Table 6.1.) Homicides committed with a firearm declined by 27%, from 18,253 in 1993 to 13,252 in 1997.
• Four of five victims of both fatal and nonfatal gunshot wounds from crime were male. About half were African-American males, and about half of those were between the ages of fifteen and twenty-four. About one in five victims of nonfatal gunshot wounds from crime was Hispanic.

FIGURE 6.1

• More than 50% of victims of nonfatal gunshot wounds from crime were younger than twenty-five, while older victims were more common in gun-related homicides.

Of all victims of nonfatal firearm injury who were treated in emergency departments, more than half were hospitalized overnight. Most of the nonfatal incidents occurred during the commission of a crime (assault or homicide, or legal intervention, which means injuries inflicted by the police in the course of arresting or attempting to arrest lawbreakers).

A 2002 study carried out by the HELP Network, Disabilities from Guns: The Untold Costs of Spinal Cord and Traumatic Brain Injuries (Chicago: The HELP Network, 2002), examined the consequences of nonfatal firearm injuries and underscored "the critical need for a national, centralized data collection system to track their long-term after-effects." Figure 6.1 tracks the number of firearm fatalities in the United States from 1968 to 2000, and Table 6.2 reports the firearm deaths and rates as well as the estimated nonfatal firearm injuries reported to emergency departments during the same period. A comparison of the number of fatal and nonfatal firearm injuries from 1994 to 1999 is found in Figure 6.2. The graph shows a gradual decline in both areas over the five-year period.

Table 6.3 presents data on the number of fatal and nonfatal injuries amongst men and women in the United States in 2001. The table breaks down the data into such categories as sex, intent (accidental or intentional), and method of death and also provides the case fatality rate for each category. (Case fatality rate is a comparison of how often an injury is fatal versus nonfatal; a higher number indicates a greater proportion of fatalities.) For 2001, unintentional firearm injuries had an 8.4 fatality rate, while intentional firearm injuries had a fatality rate of 24.7 and self-inflicted wounds had a fatality rate of 85.

FIREARM FATALITIES

Table 6.4 shows the trend since 1970 in deaths attributable to firearms by demographic characteristics of the victims. The overall death rate has generally dropped steadily from the highs of the 1970s. Firearm injuries were the second leading cause of injury deaths in the United States in 1995, surpassed only by motor vehicle-related injuries, a circumstance that had not changed in 2001.

Age

Table 6.4 provides the firearm death rates for people aged fifteen to twenty-four years, the age group most conspicuously affected by firearms deaths. The rate of 15.5 firearms–related deaths per 100,000 in 1970 in this age group rose to a high of 26.7 in 1995 before declining to 16.7 in 2001. Table 6.4 also shows very high rates of firearms deaths among elderly males. The Los Angeles Times (December 15, 2000), citing a study by the Los Angeles-based Women against Gun Violence, reported that although gun deaths were down overall in Los Angeles County in 1999 from the previous year, firearm deaths for senior citizens, including suicides, rose 14.6%. Dr. David Trader, medical director of geriatric psychiatry services at Cedars-Sinai Medical Center in Los Angeles, pointed out that loss is a characteristic of old age, including the loss of health, family, occupation, income, and friends. In a 2002 study, "Access to Firearms and Risk for Suicide in Middle-Aged and Older Adults" (American Journal of Geriatric Psychiatry, vol. 10, no. 4, July-August

TABLE 6.2

2002), Yeates Conwell, M.D., and colleagues concluded that a handgun in the home dramatically increases the risk of suicide in men over age fifty. According to the study, in 71% of the suicides of men over sixty-five, firearms were involved. Older people who attempt suicide are five times more likely to kill themselves than younger people.

Race

Table 6.4 provides the firearm death rates for African-American males, the racial group most conspicuously affected by firearms deaths. African-American men aged twenty-five to thirty-four experienced a death rate of 145.6 per 100,000 in 1970, which declined to 77.7 per 100,000 by 2001. For African-American men aged fifteen to twenty-four, the rate fell from 97.3 per 100,000 in 1970 to 90.3 per 100,000 in 2001. There was a dramatic decrease in deaths amongst Hispanic men in all demographic ranges; for example, in Hispanic men aged twenty-five to forty-four the death rate was 42.7 per 100,000 in 1990, which fell to 19.1 per 100,000 in 2001.

FIGURE 6.2

Gender

Death rates for men and women have decreased. Table 6.4 shows that the death rate among males for firearm-related injuries fell from 24.8 in 1970 to 18.5 in 2001. For women, the rate dropped from 4.8 in 1970 to 2.8 in 2001.

International Comparison

A 1997 National Center for Health Statistics comparison of injury mortality among eleven countries provides an interesting contrast in international death rates. The eleven nations participated in a study by the International Collaborative Effort on Injury Statistics (Health, United States 1996–1997, 1997), a group of researchers sponsored by the CDC who work together to identify and develop issues for research on injury statistics. In 1994 the motor vehicle–related death rate among males fifteen to twenty-four years of age was forty-one per 100,000 in the United States. Compared with the selected countries, only New Zealand had a higher motor vehicle death rate than the United States, at sixty-three per 100,000 in 1992–93. France had a motor vehicle death rate similar to that of the United States.

The firearm death rate among males fifteen to twenty-four years old was fifty-four per 100,000 in the United States. This was far higher than the rate in ten other countries. The United States had a firearm death rate four-anda-half times the rates of Norway, Israel, and Canada, which averaged eleven to twelve per 100,000. Death rates in Scotland, the Netherlands, and England and Wales were the lowest, at about one per 100,000.

TABLE 6.3

TABLE 6.4

The firearm death rate among males fifteen to twenty-four in the United States was 32% higher than the motor vehicle death rate. In no other comparison country did the firearm death rate exceed the motor vehicle death rate.

In the United States, 63% of the firearm deaths among males in this age group were homicides, and 30% were suicides. In no other country, except the Netherlands, were

more than 25% of the firearm deaths homicides. Firearm suicide accounted for at least 70% of firearm deaths in Norway, Sweden, France, Canada, New Zealand, and Australia.

THE COST OF FIREARM INJURIES

The CDC predicts that a time may come when the number of deaths and injuries related to firearms will surpass the number of deaths and injuries related to automobile accidents nationwide. Unlike most car crash victims, who are privately insured, most gunshot victims are on public assistance or uninsured. According to the CDC, the cost of firearm fatalities per person is the highest of any injury-related death. A study by Philip J. Cook and colleagues estimated the costs of gunshot injuries nationwide in 1994 at $2.1 billion, of which taxpayers paid $1.1 billion ("The Medical Costs of Gunshot Injuries in the United States," Journal of the American Medical Association, vol. 282, no. 5, August 4, 1999). When lost productivity, lost quality of life, and pain and suffering are added to medical costs, estimates of the annual total cost of firearm violence range from $20 billion to $100 billion.

Emergency room staff members report that many victims of gun-related injuries incur multiple wounds. The more damaged the victim, the higher the cost of his or her medical care.

Medical care for the typical gunshot patient admitted to the hospital costs $101,000, not including physician fees, according to a 1996 estimate by Keith Ghezzi, an emergency-room physician and former medical director at George Washington University Medical Center in Washington, D.C. For those patients who suffer debilitating injuries as a result of gunfire, such as the loss of the use of arms and legs, the costs are much higher.

In the report "Hospitalization Charges, Costs, and Income for Firearm-Related Injuries at a University Trauma Center" (Journal of the American Medical Association, vol. 273, no. 22, June 14, 1995), Kenneth Kizer and colleagues considered how much hospitals are actually reimbursed for firearm-related injury costs. For instance, one hospital studied recovered only 38% of the total hospital charges accrued. The hospital had a loss of $2.2 million due to uninsured gunshot victims. Hospitals typically cover losses from uninsured patients through charges to patients covered by Medicare, health maintenance organizations, and other insurance plans. The researchers concluded that private health insurance pays for the majority of the treatment for firearm-related injuries even though it may cover only about one-fourth of the total injury victims. As a result, taxpayers and insurance holders pay the costs of firearm violence.

GUNS AND SELF-DEFENSE: THE STUDIES

It is impossible to determine accurately how many times each year guns are used for self-defense. But there are estimates. A 2003 survey (National Crime Victimization Survey, 1993–2001, U.S. Department of Justice, September 2003) records the self-defensive actions of victims. Table 6.5 shows that 60.5% of victims of violent crime reported taking self-defensive measures during the incident. Most victims used non-aggressive means, like getting help or trying to escape. Thirteen percent of victims tried to threaten or attack their offender—1.4% of these victims used a gun to ward off their offender.

Gary Kleck, a Florida State University criminologist and researcher, concluded that people defend themselves with firearms from 2.2 million to 2.5 million times a year ("Armed Resistance to Crime: The Prevalence and Nature of Self-Defense with a Gun," The Journal of Criminal Law & Criminology, vol. 86, no. 1, Fall 1995). If this estimate is accurate, the defensive use of firearms might save as many as seventy-five lives for every life lost to gun-related crime, because firearms are involved in about 32,000 deaths (murders, suicides, and accidents) every year.

According to Kleck, the large number of defensive gun uses (DGUs) has been confirmed in at least sixteen surveys ("What Are the Risks and Benefits of Keeping a Gun in the Home?" Journal of the American Medical Association, vol. 280, no. 5, August 5, 1998). Evidence from the surveys suggested to Kleck that DGUs are effective in preventing injuries and that the number of defensive uses in the home is about six times higher than the number of criminal/aggressive uses in the same setting.

Larry Pratt, executive director of Gun Owners of America, agreed with Kleck's research, concluding that firearms preserved lives and thus saved injury costs ("Health Care and Firearms," Journal of the Medical Association of Georgia, vol. 83, March 1994). Pratt wrote that the use of guns in self-defense saves lives and that guns prevent fifteen times more injuries than they cause, assuming 162,000 gun deaths and injuries annually.

But in contrast to Kleck's estimate of 2.2 million to 2.5 million DGUs each year, there are only about 108,000 incidents of self-defense with a firearm annually, according to the 1994 National Crime Victimization Survey. The telephone sample that Kleck used is larger than that of the national survey. Kleck asserted that many people who used their guns would probably withhold such information from a government agent; therefore the national survey must under-report DGUs. Most firearms scholars have relied on the estimates of either Kleck or the National Crime Victimization Survey.

Tom W. Smith of the National Opinion Research Center at the University of Chicago concluded that both estimates were "off the mark" ("A Call for a Truce in the DGU War," The Journal of Criminal Law & Criminology, vol. 87, no, 4, Summer 1997). In Smith's opinion, the National Crime Victimization Survey estimates were too low and Kleck's estimates were too high. Smith said more studies are needed.

SAFE STORAGE OF GUNS IN THE HOME

If a gun is to be used for self-defense, does it make sense to keep it unloaded and locked? This is a question

TABLE 6.5

asked by people who oppose the growing movement to enact safe-storage laws and laws that hold gun owners criminally liable for any injury caused by a child gaining unsupervised access to a gun. While there are no federal child-access prevention (CAP) laws, the Brady Center to Prevent Handgun Violence reported that at least eighteen states and a handful of cities have some kind of CAP law. Gun control advocates are pressing for similar legislation at the federal level.

A pro-gun organization called GunCite (http://www.guncite.com [accessed January 30, 2005]) called CAP legislation "an attack on the legitimate use of firearms for self-defense," said it is unconstitutional at the federal level, and wondered: "If society wants to hold people accountable for genuinely negligent actions or child endangerment, it should do so across the board rather than single out firearms. (For example, far more children drown in private swimming pools than are killed in gun accidents.)" In the same vein, a Detroit Free Press analysis entitled "Trigger Locks May Not Be Solution to Gun Problems" by Dawson Bell (March 29, 2000) quoted gun rights advocate Don Kates: "So the question for the legislature should be: Is a parent criminally responsible for leaving an unlocked container of bleach below the sink?" Opponents of CAP laws say they are an intrusion on parental rights.

Unintentional injuries (primarily from motor vehicle accidents, drowning, fires and burns, firearms, suffocation, falls, and traffic accidents) are the leading cause of death among young children and teenagers. (See Figure 6.3.) A study by Dr. Peter Cummings and colleagues theorized that CAP laws significantly reduced unintentional firearms deaths of children under age fifteen in twelve states where the laws had been in effect for at least one year ("State Gun-Safe-Storage Laws and Child Mortality Due to Firearms," Journal of the American Medical Association, vol. 278, no. 13, October 1, 1997). The researchers found that between 1990 and 1994, unintentional shooting deaths in those states were reduced by an average of 23%. The study was criticized because it did not show that compliance with safe-storage laws was responsible for the reduction in shooting deaths. A follow-up study concluded that CAP laws had a significant effect only in Florida, one of three states where the penalty for unsafe storage was a felony rather than a misdemeanor (D. W. Webster and M. Starnes, "Re-Examining the Association between Child Access Prevention Gun Laws and Unintentional Shooting Deaths of Children," Pediatrics, vol. 106, December 2000).

A 2004 study conducted by Johns Hopkins School of Public Health and published in the Journal of the American Medical Association ("Association between Youth-Focused Firearm Laws and Youth Suicides," vol. 292, no. 5, August 4, 2004) concluded that CAP laws are effective in reducing teenage suicides. The study found that up to three hundred teenage suicides have been prevented in the eighteen states that have CAP laws.

Would parents change their gun storage practices because of CAP laws? The National Rifle Association (NRA) contends that responsible parents already practice safe storage. Yet evidence shows that while many gun owners report following safety rules, a sizable minority do not. A 1996 study (Y. D. Senturia et al., "Gun Storage Patterns in U.S. Homes with Children," Archives of Pediatric Adolescent Medicine, vol. 150, no. 3, March 1996) reported that 12% of gun owners with small children stored a gun loaded and unlocked.

Safety Programs to Protect Young Children

In 1988 the NRA created the "Eddie Eagle Gunsafe Program" for gun safety. Eddie Eagle is a school-based program that teaches gun safety to young children (pre-school through sixth grade). With the help of a cartoon character, Eddie the Eagle, kids are taught that when they find a gun they should not touch it, but instead leave the area and tell an adult. The Violence Policy Center views the Eddie the Eagle Program as a marketing tool for the NRA:

The Eddie Eagle program employs strategies similar to those utilized by America's tobacco industry—from youth "educational" programs that are in fact marketing tools to the use of appealing cartoon characters that aim to put a friendly face on a hazardous product. The hoped-for result is new customers for the industry and new members for the NRA.

A 2004 study on the efficacy of the Eddie Eagle program (B. J. Gatheridge et al., "Comparison of Two Programs to Teach Firearm Injury Prevention Skills to Six- and Seven-Year-Old Children," Pediatrics, vol. 114, September

FIGURE 6.3

2004) showed that the NRA program was effective in teaching young children to verbalize the safety skills message. However, children who received behavior skills training—programs that incorporate active learning approaches such as modeling, rehearsal, and feedback—were more likely to exhibit the desired safety skills around guns.

AVAILABILITY OF GUNS

Public health officials who seek to reduce injuries and deaths from firearms point to the ready availability of guns, especially handguns and, more recently, assault guns, as a major obstacle. They believe that injuries and deaths would be reduced if guns were harder to acquire and if they were properly stored. Opposing them are gun owners, who believe that the use of guns for self-defense prevents many injuries and deaths.

According to David Hemenway in Private Guns, Public Health (Ann Arbor, MI: The University of Michigan Press, 2004), supporters of a public-health approach to gun safety and gun manufacturers can work together to reduce gun injuries and death. He suggested several actions for gun manufacturers to reduce gun violence:

• Help increase the efficiency of law enforcement efforts
• Increase the safety of guns
• Do not develop new products that pose a danger to public health
• Fund and implement technological innovations that increase gun safety.

NATIONAL GOALS

The goals of the public health establishment for 2000 were set forth in Healthy People 2000 (U.S. Department of Health and Human Services), released in 1990. The nation's progress in meeting those goals as of 1998 was evaluated in Healthy People 2000 Final Review, released in 2001. The following is a summary of some of the goals related to firearm injuries and deaths and the Department of Health and Human Services analysis, plus the progress (where applicable) in meeting those goals:

• Goal: Reduce suicides to no more than 10.5 per one hundred thousand people. Gunshot injuries cause a majority of suicide deaths, and much of the increase in suicide rates since the 1950s corresponded to the rise in firearm-related deaths. However, while most successful suicides involve a firearm, most attempted suicides are caused by taking pills and by inflicting minor lacerations (cuts). The goal was met. By 1998 the suicide rate was 10.4 per one hundred thousand people.
• Goal: Reduce weapons-related violent deaths to no more than 12.6 per one hundred thousand people. The violent and accidental use of firearms is the second most important contributor, after motor vehicles, to injury deaths. Suicides and homicides accounted for more than 90% of all firearm-related deaths and more than 95% of knife-related deaths. Of the approximately twenty-one thousand homicides that occur in the United States annually, more than 60% involve firearms and about 20% involve knives. In 1994 firearms caused 38,505 deaths: 49% from suicides, 46% from homicide, and 4% from unintentionally inflicted injuries. The goal was met. By 1998 the rate of weapons-related violent deaths had declined to 11.3 per one hundred thousand people. For African-Americans, the rate was 22.7 (the goal was 30).
• Goal: Reduce by 20% the incidence of weapon-carrying by adolescents fourteen to seventeen years old (to eighty-six incidents per one hundred thousand students per month). Many experts consider the immediate availability of firearms and other lethal weapons to be the factor most likely to turn a violent disagreement or conflict into a lethal one. Regardless of their views on gun control, few people would argue that adolescents should have ready access to loaded firearms or other lethal weapons at school or on the streets; nonetheless, many adolescents do. The goal was met. By 1999 the rate of weapon-carrying had fallen to sixty-eight incidents per one hundred thousand students per month. This goal and the findings were based on surveys in about eleven thousand selected schools.
• Goal: Reduce by 20% (to 16%) the proportion of adults who possess weapons that are kept loaded and unlocked. Many homicides and suicides are committed on impulse, and a substantial portion of these deaths might be prevented if lethal weapons are not immediately available and if guns and ammunition are properly stored. The impulsive nature of most homicides is reflected in the fact that half of the twenty thousand or so homicide victims in the United States each year are killed by persons they know. The nation moved toward this goal. By 1998, 19% of adults reported storing weapons that were loaded and unlocked.
• Goal: Enact in all fifty states handgun storage laws to minimize the likelihood of discharge by children. While the death rate for children is generally lower than that of young and middle-aged adults, the greatest opportunities to prevent firearm-related deaths are probably among children. The nation moved toward meeting this goal. While only one state (Florida) had a firearm storage law in 1990, eighteen states had such laws in 2004.