Chapter 6
Gun-Related Injuries and Fatalities

NONFATAL GUNSHOT INJURIES
FIREARM FATALITIES
THE COST OF FIREARM INJURIES
GUNS AND SELF-DEFENSE
SAFE STORAGE OF GUNS IN THE HOME
AVAILABILITY OF GUNS
NATIONAL GOALS

The public health community, which is represented at the national level by the Centers for Disease Control and Prevention (CDC), believes that collecting comprehensive data on firearm 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 similar to those that eradicated polio and reduced traffic fatalities.

The CDC's National Center for Injury Prevention and Control administers a system that tracks the numbers of firearm-related injuries. The data are available through the Web-based Injury Statistics Query and Reporting System (WISQARS; http://wwwcdcgov/ncipc/wisqars/). This interactive, user-friendly database provides reports of injury-related data of all types, including firearm injuries, both fatal and nonfatal.

The CDC also has a state-based system, the National Violent Death Reporting System (NVDRS; http://www.cdc.gov/ncipc/profiles/nvdrs/default.htm), that collects information about violent deaths, including firearm deaths, from a variety of sources in some states. These sources include law enforcement, medical examiners and coroners, crime laboratories, and death certificates. These data help detail the circumstances that might have contributed to the death. Furthermore, they help each participating state design and implement prevention and intervention efforts tailored to that state’s needs.

The CDC notes in “National Violent Death Reporting System State Profiles” (August 29, 2007, http://www.cdc.gov/ncipc/profiles/nvdrs/state_profiles.htm) that as of August 2007 seventeen states were funded by the NVDRS: Alaska, California (a limited number of cities and counties), Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin. The CDC’s goal is to have all fifty states be part of the system.

NONFATAL GUNSHOT INJURIES

Table 6.1 shows WISQARS data for the numbers of nonfatal gunshot injuries and the rates per one hundred thousand population from 2001 to 2006. Both the number of injuries and the rate of these injuries increased overall during this period. However, the increase was not consistent over these years. In 2001 there were 63,012 non-fatal gunshot injuries, and this number declined to 58,841 in 2002, shot up to 65,834 in 2003, and then declined somewhat in 2004 to 64,389. Between 2004 and 2006 the number of nonfatal gunshot injuries rose steadily, though, to 71,417 injuries in 2006. This pattern of ups and downs, yet overall increase, is reflected in the rate of nonfatal gunshot injuries per one hundred thousand population over this period.

Gabriel B. Eber et al. of the CDC examine the circumstances of nonfatal gunshot injuries in “Nonfatal and Fatal Firearm-Related Injuries among Children Aged 14 Years and Younger: United States, 1993–2000” (Pediatrics, vol. 113, no. 6, June 2004). The researchers note that between 1993 and 2000, 41.5% of nonfatal firearm injuries in children aged fourteen years and younger were due to assaults and that 43.1% were due to unintentional injuries. Of those children with unintentional nonfatal gunshot injuries, approximately 80% had been shot by themselves, a friend, a relative, or another person known to them.

In another study, “Incidence and Circumstances of Nonfatal Firearm-Related Injuries among Children and Adolescents” (Archives of Pediatrics and Adolescent Medicine, vol. 155, no. 12, 2001), Elizabeth C. Powell, Edward Jovtis, and Robert R. Tanz examine the circumstances of nonfatal firearm injuries among youth under twenty years of age who were treated in hospital emergency rooms between 1993 and 1997. They determine

that 56% of those aged fifteen to nineteen years old were injured during assaults.

FIREARM FATALITIES

Table 6.2 shows the trend since 1970 of deaths attributable to firearms by age, race, and gender of the victims. The overall age-adjusted death rate from firearm-related injuries remained somewhat stable from 1970 through 1990 at about fourteen people per one hundred thousand resident population. By 1995 the rate dropped to about thirteen, and it continued to drop through 2000, to a rate of about ten. It then stabilized, with a slight decline, at about ten people per one hundred thousand through 2004.

The WISQARS data in Table 6.3 also show this stabilization in the rate of firearm deaths between 1999 and 2005, even though the numbers of deaths increased. The number of fatal gunshot injuries between 1999 and 2005 increased overall, from 28,874 to 30,694. This apparent anomaly between a stabilization in the rate of firearm deaths and an increase in the number of firearm deaths is easy to explain: the population rose during these years so that the modest rise in fatal gunshot injuries did not keep pace with the increasing population, by which the rate is calculated. In 1999 the rate of fatal gunshot injuries was 10.30 per 100,000, and the rate fell slightly to 10.22 in 2005.

Deaths from firearm injuries do not result only from intentional use of a firearm to cause injury or death in another. Deaths also arise from unintentional use. Results from the NVDRS from sixteen states in 2005 show the number and percentage of deaths resulting from the unintentional use of firearms and the circumstances of those deaths. (See Table 6.4.) The highest percentage of deaths occurred while playing with a gun (twenty-seven out of eighty-five deaths, or 31.8%). Sixteen out of eighty-five deaths (18.8%) occurred while hunting. In the category of mechanism of injury, the highest percentage of deaths occurred when the trigger was unintentionally pulled (seventeen out of eighty-five, or 20%). Nine deaths (10.6%) occurred when a loaded gun was dropped. In “Surveillance for Violent Deaths—National Violent Death Reporting System, 16 States, 2005” (Morbidity and Mortality Weekly Report, vol. 57, no. SS-3, April 11, 2008), Debra L. Karch et al. of the National Center for Injury Prevention and Control explain that unintentional firearm deaths comprised 0.7% of the violent deaths that occurred in the NVDRS states in 2005 and occurred at a rate of 0.1 per 100,000 population.

The CDC Injury Center (June 17, 2008, http://www.cdc.gov/ncipc/osp/charts.htm) notes that suicide firearm injuries were the second-leading cause of injury deaths in the United States in 2001, surpassed only by motor vehicle accident injuries. Homicide firearm injuries were the fifth-leading cause of injury death in 2001, and unintentional falls and poisonings were number two and three, respectively. In 2003 suicide by firearm and homicide by firearm were the fourth- and fifth-leading causes of injury deaths in the United States. Motor vehicle injuries still remained first, but unintentional poisoning was second and unintentional falls were third. This pattern remained the same in 2004.

According to Karch et al., among suicide deaths alone in 2005, firearms were used most often (51.5%), followed by suffocation (hanging; 19.7%) and intentional poisoning (16.8%). By gender, males most often committed suicide with firearms (57.3%), whereas females most often used poison (36%), followed closely by firearms (30.3%). Among homicide deaths alone in 2005, firearms were used most often overall (64.5%), and in homicides of males (69%) and females (48.4%). Sharp instruments were the second-most used method of homicide overall (12.2%), followed by blunt instruments (5.3%).

Age

Table 6.2 provides the firearm death rates for all age groups. In 1970 those aged twenty-five to thirty-four had the highest death rate from firearm-related injuries—22.2 people per 100,000 population. Those aged twenty to twenty-four had the second-highest death rate of 20.3 per 100,000 that year. However, by 1980 these age groups had changed places, with twenty- to twenty-four-year-olds experiencing 26.4 deaths per 100,000 due to firearm-related injuries. Those twenty-five to thirty-four years were in second place, with 24.3 deaths per 100,000 in that year. The rates continued to rise for the twenty- to twenty-four-year-old group through 1995, whereas the death rate fell for the twenty-five- to thirty-four-year-old group during that same time, widening the gap between them. Death rates fell dramatically for both groups by 2000, rose slightly through 2002, stabilized through 2003, and then dropped in 2004.

Race

Table 6.2 also provides the firearm death rates for race. African-American males were the racial group with the highest rate of firearms deaths. African-American men aged twenty-five to thirty-four experienced a death rate of 145.6 per 100,000 population in 1970, which declined to 74.8 per 100,000 by 2000. This age group had the highest number of deaths from firearm-related injuries in 1970 and 1980. However, in 1990 a sharp rise in firearm-related deaths in the fifteen- to twenty-four-year-old age group, to 138 per

100,000, surpassed the death rate of 108.6 for twenty-five-to thirty-four-year-olds. The death rates for both fell by 2000, and continued to fall through 2004 for those fifteen to twenty-four. For twenty-five- to thirty-four-year-olds, however, the rate of firearm deaths rose after 2000 to 85.6 per 100,000 in 2002 and to 87.2 in 2003. It fell to 83.6 in 2004, but this rate was still slightly higher than that for fifteen- to twenty-four-year-olds of 80.7 per 100,000.

Hispanic men in general experienced a dramatic decrease in firearm-related deaths from 1990 through 2000, with the rate then stabilizing through 2003 and dropping slightly in 2004. (See Table 6.2.) Most dramatically, those aged fifteen to twenty-four had a death rate from firearm-related injuries of 55.5 per 100,000 population in 1990. This number rose to 61.7 in 1995 but dropped to 30.8 by 2000. By 2003 the rate had risen to 32.8 but then fell slightly in 2004. Equally dramatic was the decline in firearm-related deaths in the twenty-five- to forty-four-year-old age group. In 1990 the firearm-related death rate for this group was 42.7 per 100,000. By 2000 the rate declined to 17.3, rising slightly in 2003 to 18.6 and then falling in 2004 to 17.6.

Gender

Firearm-related death rates for both men and women have decreased. Table 6.2 shows that the age-adjusted death rate among males from firearm-related injuries fell from 24.8 in 1970 to 17.7 in 2004. For women, the rate dropped from 4.8 in 1970 to 2.7 in 2004.

THE COST OF FIREARM INJURIES

In “Medical Costs and Productivity Losses Due to Interpersonal and Self-Directed Violence in the United States” (American Journal of Preventive Medicine, vol. 32, no. 6, 2007), Phaedra S. Corso et al. state that the estimated total lifetime cost of firearm injuries due to assaults occurring in 2000 was about $17.4 billion—$822 million for medical treatment and $16.6 billion for lost work and household productivity. Costs were much higher for males than for females, with males accounting for 90% of the total costs. The estimated total lifetime cost of firearm injuries due to assaults occurring in 2000 for males was $15.7 billion—$734 million for medical treatment and $14.9 billion for lost productivity—and for females was $1.8 billion—$88 million for medical treatment and $1.7 billion for lost productivity.

Corso et al. also indicate that the estimated total lifetime cost of self-inflicted firearm injuries occurring in 2000 was only about $1 billion less, at $16.4 billion—$124 million for medical treatment and $16.3 billion for lost productivity. Once again, costs were much higher for males than for females, with males accounting for 90% of the total costs. The estimated total lifetime cost of self-inflicted firearm injuries occurring in 2000 for males was $14.9 billion—$101 million for medical treatment and $14.8 billion for lost productivity—and for females was $1.6 billion—$23 million for medical treatment and $1.6 billion for lost productivity.

Notice that the proportion of the costs for medical treatment versus lost productivity is lower for the self-inflicted injuries than for the assault injuries. This difference is because the death rate for self-inflicted (suicide) firearm injuries is higher than the death rate for firearm injuries due to assaults. Medical treatment costs are low with a high proportion of deaths, but costs due to lost productivity are very high. Corso et al. reveal that the

overall fatal rate for firearm injuries due to assault are four per one hundred thousand population versus six per one hundred thousand overall for self-inflicted firearm injuries. For men, the rates were seven per one hundred thousand when firearm injuries were inflicted during assaults and eleven per one hundred thousand when self-inflicted. For women, the rates were one per one hundred thousand and two per one hundred thousand, respectively.

GUNS AND SELF-DEFENSE

It is impossible to determine accurately how many times each year guns are used for self-defense, but there are estimates. In “Armed Resistance to Crime: The Prevalence and Nature of Self-Defense with a Gun” (Journal of Criminal Law and Criminology, vol. 86, no. 1, 1995), Gary Kleck and Marc Gertz calculate that guns in general are used in self-defense about 2.5 million times per year, and that over 1.9 million of those self-defense cases involve handguns. In July 2006 Kleck noted in a personal communication that this estimate was determined using the 1993 crime rate and “because crime rates, and thus opportunities for self-defense, have declined by about half since then, the number of defensive gun uses has probably declined by a similar amount.”

Deborah Azael and David Hemenway of Harvard University surveyed 1,906 adults across the United States to determine whether individuals had been threatened or intimidated with a gun at home or had used a gun in self-defense at home. They indicate in “‘In the Safety of Your Own Home’: Results from a National Survey on Gun Use at Home” (Social Science and Medicine, vol. 50, no. 5, 2000) that 5% percent of the respondents reported having a gun displayed against them in the home within five years before the survey. Less than 1% reported using a gun in self-defense in the home within that same time period. After analyzing the complete data, Azael and Hemenway conclude that “in the home, hostile gun displays against family members may be more common than gun use in self-defense, and that hostile gun displays are often acts of domestic violence directed against women.”

Craig Perkins of the Bureau of Justice Statistics reports in “Weapon Use and Violent Crime” (September 2003http://www.ojp.usdoj.gov/bjs/pub/pdf/wuvc01.pdf) that in 2003 well over half (60.5%) of victims of violent crime reported taking self-defensive measures during an assault. Most victims used nonaggressive means, such as getting help or trying to escape. Thirteen percent of victims tried to threaten or attack their offender—0.7% of these victims used a gun to ward off their attacker.

David Hemenway and Matthew Miller of Harvard University surveyed approximately fifty-eight hundred California adolescents aged twelve to seventeen to determine the prevalence of gun threats versus the use of guns for self-defense among them. In “Gun Threats against and Self-Defense Gun Use by California Adolescents” (Archives of Pediatric Adolescent Medicine, vol. 158, no. 4, April 2004), they state that about 4% of those surveyed reported ever being threatened with a gun. Only 0.3% reported ever using a gun in self-defense. Hemenway and Miller conclude that self-defense gun use in adolescents is rare.

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 up? This is a question asked by people who oppose safe-storage laws and laws that hold gun owners criminally liable for any injury caused by a child gaining unsupervised access to a gun. The Legal Community against Violence notes in Child Access Prevention (CAP) Laws: An Evaluation and Comparative Analysis of Federal, State and Local Gun Laws (February 2008, http://www.lcav.org/library/reports_analyses/Reg Guns.entire.report.pdf) that as of 2008 twenty-eight states and the District of Columbia had CAP laws. Gun control advocates are pressing for similar legislation at the federal level.

In “Trigger Locks and Mandatory Storage Laws” (December 25, 2003, http://www.guncite.com/gun_control_rrtrigger.html), the pro-gun organization GunCite calls CAP legislation “an attack on the legitimate use of firearms for self-defense” and states that it is unconstitutional at the federal level. Furthermore, the organization wonders, “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 kids drown in private swimming pools than are killed in gun accidents.)”

Unintentional injuries (primarily from motor vehicle accidents, drowning, fires and burns, firearms, suffocation, falls, and traffic accidents) are the leading cause of death among fifteen- to twenty-four-year-olds. (See Table 6.5.) According to Hsiang-Ching Kung et al. of the National Center for Health Statistics, in “Deaths: Final Data for 2005” (National Vital Statistics Reports, vol. 56, no. 10, April 24, 2008), unintentional injuries are also the leading cause of death for children under the age of fifteen.

Daniel W. Webster et al. conclude in the “Association between Youth-Focused Firearm Laws and Youth Suicides” (Journal of the American Medical Association, vol. 292, no. 5, August 4, 2004) that CAP laws are effective in reducing teenage suicides. They find that as of 2004 up to three hundred teenage suicides had been prevented in the states that have CAP laws.

Conversely, Matthew R. Rosengart et al. note in “An Evaluation of State Firearm Regulations and Homicide and Suicide Death Rates” (Injury Prevention, vol. 11, no. 2,

2005) that research does not support the hypothesis that CAP laws help reduce teenage suicide. The researchers conclude that “no law was associated with a statistically significant reduction in firearm homicide or suicide rates.”

In “Gun Storage Practices and Risk of Youth Suicide and Unintentional Firearm Injuries” (Journal of the American Medical Association, vol. 293, no. 6, February 9, 2005), David C. Grossman et al. investigate the relationship between gun storage practices and unintentional injuries and suicide. Table 6.6 denotes as 1.00 the occurrence

rate of unintentional firearm injuries and suicide when there is easy access to guns and ammunition. Numbers less than 1.00 in the table show that the odds of injury or suicide are less than the accessible guns and ammunition rate. Numbers more than 1.00 show that the odds are greater than the accessible guns and ammunition rate. All the gun storage practices listed in the table result in decreased odds of unintentional firearm injury or suicide by firearm. Only the use of a trigger lock shows a higher rate for unintentional injuries, but not for suicide. Whether CAP laws motivate people to store guns safely was not considered in this study.

Lisa Hepburn et al. of Harvard University conclude in “The Effect of Child Access Prevention Laws on Unintentional Child Firearm Fatalities, 1979–2000” (Journal of Trauma Injury, Infection, and Critical Care, vol. 61, no. 2, 2006) that CAP laws may have influenced the continued reduction in unintentional firearm death rates that occurred from 1979 to 2000 nationally among children. The researchers determine that “the decrease in rates of unintentional firearm deaths for children 0 to 14 in CAP law states exceeded the average for states without CAP laws in 9 of the 14 states for which data were available.” Statistical analyses of Hepburn et al.’s data “showed a significant association between CAP laws and rates of unintentional firearm deaths forchildren0to14years old.”

Would parents change their gun storage practices because of CAP laws? The National Rifle Association of America (NRA) contends that responsible parents already practice safe storage. However, evidence shows that even though many gun owners report following safety rules, a sizable minority do not. In 1996 Yvonne D. Senturia, Katherine Kaufer Christoffel, and Mark Donovan reported in “Gun Storage Patterns in U.S. Homes with Children” (Archives of Pediatric Adolescent Medicine, vol. 150, no. 3) that 12% of gun owners with small children stored a gun loaded and unlocked. In 2006 Renee M. Johnson et al. reported the results of their study in “Are Household Firearms Stored Less Safely in Homes with Adolescents?: Analysis of a National Random Sample of Parents” (Archives of Pediatric Adolescent Medicine, vol. 160, no. 8). The researchers indicated that slightly more gun owners follow gun storage safety rules. Johnson et al. ascertained that gun owners with small children stored a gun loaded and unlocked 8% of the time, and parents of adolescents stored guns this way 10% of the time. No analysis was conducted to determine whether the change was correlated with adherence to CAP laws.

Safety Programs to Protect Young Children

In 1988 the NRA created the Eddie Eagle Gunsafe Program http://www.vpc.org/fact_sht/eddiekey.htm) that the program is 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.”

Brian J. Gatheridge et al. note in “Comparison of Two Programs to Teach Firearm Injury Prevention Skills to 6- and 7-Year-Old Children” (Pediatrics, vol. 114, no. 3, September 2004) that the NRA program is effective in teaching young children to verbalize the safety skills message. However, they conclude that children who received behavior skills training—programs that incorporate active learning approaches such as modeling, rehearsal, and feedback—are more likely to exhibit the desired safety skills around guns.

In “Peer Tutoring to Prevent Firearm Play: Acquisition, Generalization, and Long-Term Maintenance of Safety Skills” (Journal of Applied Behavior Analysis, vol. 41, no. 1, 2008), Candace M. Jostad et al. support the behavioral skills training approach and show that six- and seven-year-old children acquire and maintain firearm safety skills when behavioral skills training is used and is taught by other children trained in the techniques.

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 (2006), supporters of a public health approach to gun safety can work with gun manufacturers to reduce gun injuries and death. He suggests 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

Released in January 2000, Healthy People 2010 (http://www.healthypeople.gov) is a set of national health objectives developed under the leadership of a variety of U.S. governmental agencies, such as the President’s Council on Physical Fitness and Sports, the CDC, the U.S. Food and Drug Administration, and the Health Resources and Services Administration. This national health initiative builds on Healthy People : The Surgeon General’s Report on Health Promotion and Disease Prevention (1979 http://profiles.nlm.nih.gov/NN/B/B/G/K/segments.html) and Healthy People 2000 (September 1990 http://wwwcdcgov/nchs/about/otheract/hp2000/hp2000htm). The following are two Healthy People 2000 goals that are related to firearms, their outcomes, and the continuing objectives of Healthy People 2010.

• Healthy People 2000 goal:Reduce firearm-related deaths to no more than 12.6 per 100,000 people. Healthy People 2000 summary of the problem: 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, even though most successful suicides involve a firearm, most attempted suicides are caused by taking pills and by inflicting minor lacerations (cuts). The Healthy People 2000 goal was met. Kung et al. indicate that by 1999 the suicide rate was 10.5 per 100,000 people. The Healthy People 2010 objective is to further reduce suicides to no more than five per one hundred thousand people. However, Kung et al. also note that the suicide rate had risen to 10.9 per 100,000 in 2005, which was above the Healthy People 2000 goal.
• Healthy People 2000 goal:Reduce firearm-related deaths to no more than 12.6 per 100,000 people. The Healthy People 2000 goal was met. In 1999 there were 10.3 firearm deaths per 100,000. (See Table 6.3.) The Healthy People 2010 objective is to further reduce firearm-related deaths to no more than 4.1 per 100,000 people. However, Table 6.3 shows that in 2005 there were 10.22 firearm deaths per 100,000, which was well above the goal.