Violence in America

The physicians of the Eastern Association for the Surgery of Trauma (EAST) care for the victims of firearm violence on a daily basis. Therefore, they are uniquely qualified to understand the alarming frequency and lethal nature of these injuries, the substantial financial and emotional costs, and the devastating impact on American society. The membership of EAST recognizes that the staggering costs, disabilities, and deaths that result from trauma that is specifically caused by firearms currently constitute a public health hazard. Firearm violence continues to grow unabated and has reached epidemic proportions in the United States (U.S.) [1-12]. It is estimated that firearms will become the leading cause of trauma deaths nationwide by the year 2003 if current trends continue [7,8]. The purpose of this article is to analyze critically the scope and nature of violence as it relates to firearms, and to focus on the firearm itself as one factor that contributes to the presence and growth of violence. It is hoped that, like any other disease, such an analysis will lead to the development of rational suggestions for the reduction and prevention of firearm injury. MAGNITUDE OF THE PROBLEM Profile of Firearm Deaths As of 1991, firearms are the second leading cause of injury-related death in this country, and it is estimated that for every such death there are several nonfatal firearm injuries [3,5,7,8,10,11]. The National Center for Health Statistics reports that, in 1991, firearms became the leading cause of trauma deaths in California, Nevada, New York, Virginia, the District of Columbia, Texas, and Louisiana. Over one million American civilians have been killed by firearms since 1933 [1]. That is greater than the combined total of all American soldiers killed in every war ever fought. From 1985 to 1991, 103,000 more Americans died from firearms than from AIDS [13]. In 1991 alone, there were 38,317 firearm deaths in this country, for a rate of 17.3 of 100,000 [7,8]. This represents a 21% increase since 1985 [14] and a 60% increase since 1968 [7,8,14]. Therefore, every 2 years, more Americans are killed by firearms than were killed in all 11 years of the Vietnam war. Most important, if the current trend continues, firearms will become the leading cause of trauma death nationwide by the year 2003 [7,8]. During 1991, 5356 firearm deaths occurred in young Americans under the age of 20 [15]. Over 80% of these firearm deaths among American youths now occur in the 15- to 19-year age group, a 75% increase over the last 20 years. Furthermore, death by firearm has now risen to the fifth leading cause of mortality in children under the age of 14 [16]. Approximately 15 American youths under 20 years of age die every day from firearms [5,15-18]. There are three major categories into which firearm deaths are grouped [1]. As of 1991, suicide was the predominant cause of firearm death in this country, followed by homicide and unintentional causes. In recent years, the proportion of homicides among all U.S. firearm deaths has been steadily increasing in relation to firearm suicides [7,8]. Each of these categories merits analysis, in order to appreciate their distinct epidemiology and implications. Homicide is now the tenth leading cause of death in the United States, and it ranks among the top five causes of death in the 1- to 44-year age group. In 1991, 24,703 homicides were committed in this country. This represented a 10% increase since 1981 [4,6,12,19,20]. Approximately 47% of all firearm deaths in 1991 were due to homicide [3]. In 1991, 17,046 homicides (69% of all U.S. homicides) involved firearms [5,6,12], a doubling in number since 1968 and a tripling since 1960 [10,12]. In comparison, the U.S. population has increased by only 20% since 1960. This national firearm murder rate continues to rise every year, and it far outstrips the rate of non-firearm homicides [21]. Perhaps the most tragic aspect of homicide caused by firearms is reflected by the impact on American children and young adults. The Federal Bureau of Investigation (FBI) reports that there has been a 143% increase in the number of firearm homicides of American youths under the age of 18 between 1986 and 1992, compared with a 30% increase for Americans over the age of 18. The most common cause of death in 15- to 24-year-old black American males is firearm homicide. Their annual death rate from this cause has increased 61% between 1979 and 1989, and it has been rising more rapidly than for any other cause. Non-firearm homicides in this group have actually decreased by 29% during this same time period [19,22,23]. One study documented a 252% increase in homicides among children and adolescents between the ages of 1 to 18 in Detroit from 1980 to 1988. Most of those deaths were firearm-related, and the most significant increase occurred among 10- to 14-year-old males [24]. In addition to these mortality statistics from interpersonal violence, firearms play a dominant role in the taking of one's own life. For the 50 years between 1933 and 1982, firearm suicides among 10- to 24-year-old Americans increased by 139%, whereas non-firearm suicides in this group increased by only 32% [25]. Currently, over 30,000 suicide deaths occur annually in the U.S. In 1991, 60% of suicides involved firearms, and 48% of all firearm deaths were suicides [3,5,7,8,26]. In children 10 to 14 years old, 25% of firearm deaths are suicides. Between 15 and 34 years of age, this percentage grows to 45%, and over the age of 75, suicide accounts for 93% of all firearm deaths [14,27]. Only 3.8% of all 1991 firearm deaths in this country were unintentional, and the rate of unintentional firearm deaths has been steadily declining since 1920 [1]. Of the 1,441 such deaths that year, approximately 400 deaths were in youths under the age of 18, and 60% of those latter deaths occurred in or around the home [3,7-9]. As many as 40% of firearm deaths in children under the age of 14 are unintentional [27], with males under the age of 20 having the highest fatality rate. Almost one-third of unintentional firearm deaths are hunting-related, and most of those victims are under the age of 20. In 50% of hunting deaths caused by shooters less than 20 years of age, there was no adult supervision [28]. Cost of Firearm Injury and Death Firearm injuries are the third most costly cause of injuries in this country. Although they represent only 0.5% of all injuries, they account for 9% of the total U.S. lifetime cost of injury [29]. They rank first among fatal injuries ($373,500 per fatal injury) and fourth among hospitalized injuries ($33,000 per injury) [14]. The annual medical costs of firearm injuries in the United States exceed $4 billion [11,30]. Estimates of lifetime economic losses from this cause have risen from $14.4 billion in 1985 [31] to over $20 billion in 1990 [29]. The average cost of hospitalization for a patient with a firearm injury was found to be $6915 in 1984 [30], which translates to $19,173 in 1993 dollars. Taxpayers fund 86% of these costs, which can range up to $500,000 per patient in some centers [32]. At one trauma center in the District of Columbia, firearm injury costs in 1987 had increased 161% over 2 years, to more than $6 million per year. Almost 60% of these injuries were caused by assaults, with suicides and unintentional firearm injuries accounting for far less of the costs. A 1993 study from 44 acute care children's hospitals found an average hospital bill of $14,434 for each patient under the age of 19 who was admitted for a firearm injury [15]. These costs could be at least doubled if the additional dollars for physician fees, ambulance services, readmissions, outpatient visits, rehabilitation services, lost work time, and legal fees are considered [32,33]. A recent study from one trauma center in Seattle [34] demonstrated a substantial financial benefit if all patients with firearm injuries instead had suffered only stab wounds. This would have resulted in an annual overall savings of $1,290,000, of which $981,000 would have been public funds, in that one institution alone. International Context Firearm deaths occur over 90 times more frequently in the United States than in any other industrialized country [14]. The World Health Organization and the FBI report that, in 1990, handguns were used in the murders of 10 people in Australia, 22 in Great Britain, 68 in Canada, 87 in Japan, and 11,719 in the United States [12]. The yearly firearm homicide rate in this country ranges from 12 to 273 times the rate found in any other industrial nation, an average of 50 times the yearly rate found in the combined populations of England, Germany, and Japan [10]. In 1974, there were 1708 homicides in all of Japan and only 4% involved firearms. Of the 189 homicides in Tokyo that year, only one involved a firearm. In contrast, over 1500 homicides were reported in New York City in 1974, the majority of which involved firearms [10,35]. These international contrasts are most marked among adolescents and young adults. In 1987, there were 4223 homicides in the United States among 15- to 24-year-old males, 3187 (75%) of which involved firearms [2]. This was over 41 times the total number of firearm homicides reported that year in this age group in the combined populations of Canada, Japan, France, West Germany, Australia, England, and Sweden. In these other countries, less than 25% of all adolescent and young adult homicides involved firearms. If the U.S. homicide rate in 15- to 24-year-old males (currently 22 of 100,000) was reduced only to the level found in the country with the second highest homicide rate in this group (Scotland, 5 of 100,000), then the annual U.S. death toll would be lowered by at least 3000 lives [2]. Undoubtedly, there are multiple variables that may explain these figures, including differences in cultural values, law enforcement practices, and judicial systems. However, the existence of strict gun control laws in these other industrialized nations stands out as one major factor that contributes significantly to these striking differences. The overriding importance of firearm, and especially handgun, availability as a contributing factor to these international contrasts is supported by the fact that U.S. non-firearm homicides are only 1.4 to 9.2 times higher than that of other industrialized nations [3,10]. CONTRIBUTION OF FIREARMS TO VIOLENCE It is estimated that over 220 million firearms are currently owned by private citizens in the U.S., a number that has doubled since 1980. Firearms are now found in two-thirds of all American households, representing a 50% increase since 1980. There are over 72 million handguns in this country, which has more than doubled since 1972. Further, an additional two million handguns become available to our population each year according to the Bureau of Alcohol, Tobacco, and Firearms (BATF) [10,36,37]. The National Association of Federally Licensed Firearms Dealers and the BATF report that revenue from firearm and ammunition sales almost doubled in this country between 1987 and 1992, rising from $4.8 billion to $9.0 billion. Handguns must be considered the most dangerous of all firearms, in terms of the frequency of their violent use and their lethality. In 1990, 28% of the 1.8 million violent crimes in this country involved firearms, most commonly handguns [9]. A handgun was used in 77% of all firearm homicides that year [12], 70% of all firearm suicides, and the majority of all unintentional shootings among children in their homes [14]. Handguns alone caused 85% of all firearm homicides in this country since 1960. However, handguns comprise less than one-third of all firearms [1,6,10,14]. Most other firearms consist of rifles and shotguns. These are predominantly sporting weapons that are seven times less likely to be used in criminal violence than are handguns [9]. Handguns are the only firearms to have increased as a cause of homicides since 1988 and largely account for the rising homicide rate in this country [8]. Up to 95% of all murders of American law enforcement officers in the line of duty are committed with handguns [10]. Increasingly lethal types of handguns and ammunition have been used in criminal activities in many American cities since 1985 [6]. There is compelling evidence that relates the mere availability of firearms to the occurrence of firearm deaths [3,9,17,37,38]. The rising rate of firearm deaths in this country since 1946 closely parallels the rising national rate of firearms available for sale [1]. Domestic manufacture of firearms has more than tripled during this period [25]. In addition, the BATF reports that the number of firearms imported into this country between 1980 and 1993 has more than quadrupled. The rate of gun-related crimes in any geographic area consistently correlates with the number of guns owned in that area [5,9]. Firearms are highly lethal. They are 3 to 15 times more likely to kill with any given attempt than non-firearm weapons. It has been shown that 60% of gun assaults are fatal, compared with only 4% of knife assaults and <1% of assaults with blunt weapons [39]. The Bureau of Justice Statistics and the FBI report that most homicides are not premeditated, but are impulsive. They result from arguments and loss of temper, and the most readily available weapon is typically used. Just by eliminating the firearm from these situations, the same rate of violent assaults could result in 80% less deaths [9]. For example, Seattle, Washington was found to have a 65% higher rate of homicide than Vancouver, British Columbia, almost entirely accounted for by a fivefold greater rate of handgun homicides. The only factor that significantly differentiates these two cities is very strict gun control and the virtual impossibility of obtaining handguns in Vancouver. Non-firearm crimes occur at the same rates in these two cities [40]. The incidences of suicide and unintentional deaths are also closely related to firearm availability. In 90% of firearm suicides, guns are used only because they happen to be available. Only 8% of victims survive suicide attempts with a firearm, compared with 33% surviving drowning attempts, 73% surviving poisoning attempts, and 96% surviving knife wounds. Adolescent and adult suicides are up to five times more likely to occur in homes that have guns than in homes that do not [3,41]. The rate of handgun suicides among 12- to 24-year-old Seattle residents is ten times that of their counterparts in Vancouver [42]. Unintentional firearm deaths most commonly occur in the home, commonly afflict children, and clearly would be largely eradicated in the absence of the firearm [17,25,42-44]. Many privately owned firearms, especially handguns, are purchased for self-protection, with the perception that these weapons increase the safety and security of one's home or business. The facts prove this to be false [10,45]. Of 398 firearm deaths in homes documented in one study, only two involved an intruder shot during attempted entry. In homes with guns in that study, household members, their relatives, or acquaintances had a risk of firearm death that was 43 times more likely than the death of an intruder [46]. Although that study did not report the number of times intruders were nonfatally injured or warded off with a firearm kept in the home, it also omitted the number of nonfatal injuries to household members caused by these weapons [3]. Another study showed that, in homes with guns, unintentional shootings of household members or acquaintances were six times more likely than shootings of strangers or intruders [47]. It has also been shown that victims who use a firearm to resist an assault or robbery actually increase their own risk of injury and death [9]. Of the 24,703 homicides occurring in the United States in 1991, only 327 (1.5%) were considered justifiable, or were committed in self-defense [37]. According to the self-defense homicides committed with handguns accounted for only of all homicides in this country in The that, in the absence of guns, people do not kill or other people as frequently as they do guns are available. Although there are many that the epidemic of violence in American the and with the of firearms, especially violence to a national level that is far greater than it would be if to these weapons was One major that has been gun control is that it the to as in the second of the U.S. This is judicial at the and in that such a is not at all to the public not a law that the sale or use of firearms has been as under the second have consistently the of our to the as in the of our This must in the of firearm violence. Another laws that would the of firearms to private citizens is that this would the American public the who could these weapons and be to use In less than 30% of all firearm deaths in this country occur in the of criminal and only the [10]. Furthermore, strict gun control laws have at the impact of who and use firearms firearms and for example, have not a significant role in violent in this country since the National Firearms of their sale and in the year the of the in in a for a gun a there was a reduction in firearm homicides and a reduction in nonfatal firearm assault injuries in [3]. EAST VIOLENCE The membership of EAST is committed to the of any and all that may the current level of firearm violence in the United EAST public gun safety of firearm into prevention and increased and of our judicial and to dangerous off the the level of violence by the the for on the of the in to violence, development of that of and any other that the causes of violence and that may and dangerous especially among children and adolescents Although EAST recognizes that the who a gun in violent is an of this disease, the in this article that the firearm itself is contributing to the growth of this national Firearms be specifically for control in the same that any other public health is on the and use of handguns and other firearms are that this lead to a reduction in the of violent injury and death in this country. 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These be to violence, since violence is a many contributing However, the of the of violence not in itself the of these since these do to to a substantial reduction in violent injuries and deaths in this country The focus of the over firearm control must from the of firearm to the of to be from the and of these dangerous weapons. The current on our by violence that handguns and other firearms be more by firearm and who be to prove a for these weapons they are or The membership of EAST and to the of life. to that is as and as the violence caused by handguns and other firearms represents a to all of and that must be and by our a greater than any EAST that the will the current epidemic of firearm violence in