The Epidemiologists May Need To Dig Deeper To Understand The Problem Of Gun Violence.

If we want to advance some meaningful responses to gun violence, we need to figure out the what, who and where of the problem or, as public health researchers would say, the epidemiology of gun violence. A good start in this respect is a recent publication by one of our most prolific public health gun scholars, Garen Wintemute, whose summary of gun-violence data covering 2003-2012 appears in a symposium devoted to strategies to prevent gun violence in the Annual Review of Public Health.

Wintemute introduces the problem by noting that 313,045 Americans died from firearm-related injuries, a larger number than all the troops killed in World War II.  But on a White House gun violence website, the number for gun mortality between 2001 and 2013 is given as 150,000. How come there’s such a big difference?

conference program pic               Because to the public health community, gun violence means every kind of injury caused by gunfire, whether the gun is pointed at the user or at someone else.  The fact is that a majority of gun killings are suicides, not homicides, and among certain populations, such as elderly White men in certain Western states, suicides account for virtually all gun mortalities, with homicides contributing nothing to total gun mortality at all.  This is not the time or place to engage in a discussion about the causal/responsive differences between gun suicides and gun homicides; suffice it to say that Wintemute and other public health researchers clearly acknowledge that homicide and suicide are subsets of a generic problem – access to guns – each of which needs to be understood on its own terms.

Where Wintemute’s careful and thorough analysis of CDC violent mortality data bumps up against a serious limitation (which he acknowledges) is not in terms of defining gun violence to include both homicide and suicide, but in the fact that he is forced to create an epidemiology of gun violence without being able to utilize data on non-fatal gun injuries, the incidence of which is at least twice as high each year as the number of people getting killed with guns.

Not only is the non-fatal gun injury rate twice as high as the gun mortality rate (suicide and homicide), but while the overall gun mortality rate has been fairly steady over the years covered by Wintemute’s research, the non-fatal gun injury rate has shown a remarkable annual rise, from 14.11 per 100,000 in 2001 to 19.68 in 2013, an increase of nearly 40 percent!  Part of this increase is due to innovations in trauma surgery, also to the speed at which seriously-injured victims get moved from the incident site to a trauma unit and the fact that most of the jerks who use guns probably can’t shoot very straight.  Or is this increase simply due to the fact that more guns are where they shouldn’t be?  We don’t know.

Make no mistake. The costs of gun violence cannot be understood if we don’t factor in what happens when someone is shot but not killed with a gun.  Direct medical costs of treating non-fatal gun injuries are 30-40% higher than the costs of dealing with any other serious injury; these numbers don’t include the frequent, long-term costs of post-discharge therapies, as well as the excessive loss of wages that often are the result of the physical and mental damage resulting from guns. A recent estimate of the total annual cost of all gun violence – mortality and morbidity – as being around $229 billion, may be an underestimate by far.

One other point which emerges from Wintemute’s work deserves comment here.   Of the fourteen states that rank highest in suicides and homicides, eleven are located in the South.  Some of these states, like Alabama, Louisiana and Mississippi, experience gun violence similar to Panama and South Africa, not yet Honduras, but not far behind. If we construct an epidemiology to help us figure out gun violence, the answers and strategies for some may not be sufficient for all.

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