Private Guns, Public Health

PRIVATE GUNS PUBLIC HEALTH\ \ By David Hemenway \ THE UNIVERSITY OF MICHIGAN PRESS\ Copyright © 2004 David Hemenway\ All right reserved.\ ISBN: 978-0-472-03162-7 \ \ \ Chapter One\ GUNS AND AMERICAN SOCIETY \ The landmarks of political, economic and social history are the moments when some condition passed from the category of the given into the category of the intolerable.... I believe that the history of public health might well be written as a record of successive re-defining of the unacceptable. -G. Vickers\ On an average day during the 1990s in the United States, firearms were used to kill more than ninety people and to wound about three hundred more. Each day guns were also used in the commission of about three thousand crimes. The U.S. rates of death and injury due to firearms and the rate of crimes committed with firearms are far higher than those of any other industrialized country, yet our rates of crime and nonlethal violence are not exceptional. For example, the U.S. rates of rape, robbery, nonlethal assault, burglary, and larceny resemble those of other high-income countries (Van Kesteren et al. 2000); however, our homicide rate is far higher than that of other high-income nations (Krug, Powell, and Dahlberg 1998). This chapter discusses the nature and extent of the firearms injury problem in the United States (Hemenway 1995, 1998a) and describes the prevalence of firearms in contemporary America.\ THE SCOPE OF THE GUN PROBLEM\ Perhaps the most appropriate international comparisons are those between the United States and other developed "frontier" countries where English is spoken: Australia, Canada, and New Zealand. These four nations have roughly similar per capita incomes, cultures, and histories (including the violent displacement of indigenous populations). In 1992, the rates of property crime and violent crime were comparable across these four countries (Mayhew and van Dijk 1997); with the decline in U.S. crime, by the end of the century U.S. crime rates were actually lower than in these other countries (table 1.1). What distinguishes the United States is its high rate of lethal violence. In 1992 our murder rate was five times higher than the average of these three other countries (Krug, Powell, and Dahlberg 1998); in 1999-2000 it was still about three times higher (table 1.2). In contrast to these other nations, most of our murderers use guns. Comparisons with other high-income countries make our gun/lethal violence problem look even worse (Killias 1993; Hemenway and Miller 2000).\ Canada, Australia, and New Zealand all have many guns, though not nearly as many handguns as the United States. The key difference is that these other countries do a much better job of regulating their guns. Their experience and that of all high-income nations shows that when there are reasonable restrictions on guns, gun injuries need not be such a large public health problem. Their experience also shows that it is possible to live in a society with many guns yet one in which relatively few crimes are committed with guns.\ A nation may be judged by how well it protects its children. In terms of lethal violence, the United States does very badly. For example, a comparison of violent deaths of five- to fourteen-year-olds in the United States and in the other twenty-five high-income countries during the 1990s shows that the United States has much higher suicide and homicide rates, almost entirely because of the higher gun death rates. The United States has ten times the firearm suicide rate and the same nonfirearm suicide rate as these other countries, and the United States has seventeen times the firearm homicide rate and only a somewhat higher nonfirearm homicide rate. Our unintentional firearm death rate is nine times higher (table 1.3).\ Of particular concern was the rise in children's violent deaths in the early 1990s. For example, between 1950 and 1993, the overall death rate for U.S. children under age fifteen declined substantially (Singh and Yu 1996) because of decreases in deaths from both illness and unintentional injury. However, during the same period, childhood homicide rates tripled and suicide rates quadrupled; these increases resulted almost entirely from gun violence.\ Though gunshot wounds often result in death, even nonfatal wounds can be devastating, leading to permanent disability. Traumatic brain injury and spinal cord injuries are two of the more serious firearm-related injuries. For example, nonfatal gunshot injuries are currently the second-leading cause of spinal cord injury in the United States; it is estimated that each year, more than two thousand individuals who are shot suffer spinal cord injuries (DeVivo 1997; Cook and Ludwig 2000). Spinal cord injuries from gunshot wounds also tend to be quite serious-gunshot wounds are more likely than non-violence-related traumatic spinal cord injuries (e.g., from falls or motor vehicle collisions) to lead to paraplegia and complete spinal cord injury (McKinley, Johns, and Musgrove 1999).\ The psychological ravages of firearm trauma can be especially long-lasting. For example, compared to other traumatic injuries, gunshot wounds are more likely to lead to the development of posttraumatic stress disorder (PTSD) in children (Gill 1999). Chronic PTSD following firearm injury is common: in one study, 80 percent of hospitalized gunshot-wound victims reported moderate or severe symptoms of posttraumatic stress eight months after the incident (Greenspan and Kellermann 2002); in another study, 58 percent of firearm assault victims met the full diagnostic criteria for PTSD-3 thirty-six months after the incident (Burnette 1998). Even witnessing firearm violence can have serious psychological consequences. In one study, high school students who witnessed firearms suicides were at higher risk than other demographically similar students to develop psychopathology-specifically, anxiety disorders and PTSD (Brent et al. 1993a).\ The direct medical costs of gunshot wounds were estimated at six million dollars per day in the 1990s. The mean medical cost of a gunshot injury is about seventeen thousand dollars and would be higher except that the medical costs for deaths at the scene are low (Cook et al. 1999). Half of these costs are borne directly by U.S. taxpayers; gun injuries are the leading cause of uninsured hospital stays in the United States (Coben and Steiner 2003). The best estimate of the cost of gun violence in America, derived from asking people how much they would pay to reduce it, is about one hundred billion dollars per year (Cook and Ludwig 2000).\ Fortunately, many reasonable policies can reduce this enormous and, among high-income nations, uniquely American public health problem-without banning all guns or handguns and without preventing responsible citizens from keeping firearms.\ THE FACTS ABOUT GUN OWNERSHIP\ The United States "almost certainly has more firearms in civilian hands than any other nation in the world." -Gary Kleck\ The role of firearms in American history has been shrouded in myth and legend, none greater than the images of revolutionary militiamen with their trusty rifles defeating the world's most powerful nation and frontier cowboys-tough, brave, and independent- whose remarkable shooting made them memorable and heroic figures. Yet the key firearm in the Revolution was the inaccurate one-shot musket, and the regular army won the war. The militia had very limited success: George Washington considered it to be a "broken reed" (Emory 1904; Peterson 1956; Ropp 1959; Russell 1967; Kennett and Anderson 1975; Higginbotham 1988; Whisker 1997; Gruber 2002; Rakove 2002).\ Long the subject of twentieth-century heroic myth, the realistic image of the nineteenth-century cowboy is "a hired hand with a borrowed horse, a mean streak, and syphilis." Cowboys were mostly young, single, itinerant, irreligious, southern-born men who lived, worked, and played in male company. Many were combat veterans, and almost all carried firearms. Youthful irresponsibility, intoxication, and firearms led to so many murders and unintentional injuries at the end of the trail that laws were enacted to force cowboys to check their guns before they entered towns (Courtwright 1996).\ For today's gun enthusiasts, the citizen-soldier and the cowboy lawman remain two archetypes of American history (Kohn 2000). But what is not a myth is that America is currently awash with guns. It is estimated that there are more than two hundred million working firearms in private hands in the United States-as many guns as adults.\ The total number of firearms in civilian hands has increased rapidly in the past forty years. Seventy percent of all new guns purchased in America during the twentieth century were bought after 1960. The type of gun purchased has also changed. In 1960, only 27 percent of the yearly additions to the gunstock were handguns; by 1994, that number had doubled to 54 percent (Blendon, Young, and Hemenway 1996; Cook and Ludwig 1996; Kleck 1997b).\ While the number of guns has increased, the percentage of American households reporting that they own guns has declined markedly in recent years, from about 48 percent in 1973 to closer to 35 percent today (Blendon, Young, and Hemenway 1996; T. W. Smith 2001). This decline appears in part to result from the decreasing number of adults in each household and, since 1997, from a decline in the proportion of adults who personally own firearms (T. W. Smith 2001). However, current gun owners have been buying additional firearms; the average number of firearms owned by gun owners has been increasing in recent decades.\ Currently, one in four adults owns a gun of some kind, but owners of four or more guns (about 10 percent of the adult population) are in possession of 77 percent of the total U.S. stock of firearms (Cook and Ludwig 1996). Many people, especially women, who live in households with a gun do not own any guns. Approximately 40 percent of adult males and 10 percent of adult females are gun owners (Cook and Ludwig 1996; T. W. Smith 2001). Even though we live in a land of firearms, the majority of males do not own guns, and only about one woman out of ten is a gun owner.\ The percentage of households with long guns (rifles and shotguns) fell from 40 percent in 1973 to 32 percent in 1994, but household handgun ownership rose from 20 to 25 percent. Since the mid-1990s, even household handgun ownership has been declining (T. W. Smith 2001). Perhaps 16 percent of U.S. adults currently own handguns.\ People report owning guns primarily for hunting, target shooting, and personal protection. The reasons for ownership differ for long guns and handguns. Handguns are owned primarily for protection, while long guns are used mainly for hunting and target shooting. While all guns pose risks for injury, compared to their prevalence in the gun stock, handguns are used disproportionately in crimes, homicides, suicides, and gun accidents. Thus, some proposed gun policies focus on handguns rather than long guns.\ Gun ownership varies across geographic regions; it is highest among households in the South and in the Rocky Mountain region and lowest in the Northeast. It is higher in rural areas than urban areas; it is higher among conservatives than among moderates or liberals (Davis and Smith 1994; T. W. Smith 2001).\ One of the most important predictors of gun ownership is whether one's parents had a gun in the home. Gun ownership is highest among those over forty years old and is more prevalent among those with higher incomes. While gun owners come from the entire spectrum of American society, people who admit to having been arrested for a nontraffic offense are more likely to own guns (37 percent versus 24 percent for those without an arrest) (Cook and Ludwig 1996); owners of semiautomatics are more likely than other gun owners to report that they binge drink (Hemenway and Richardson 1997); and combat veterans with PTSD appear more likely than other veterans to own firearms (and to engage in such potentially harmful behavior as aiming guns at family members, patrolling their property with loaded guns, and killing animals in fits of rage) (Freeman, Roca, and Kimbrell 2003).\ A few fringe groups of gun owners may someday pose political problems for the United States. The militia movement made the front pages after the Oklahoma City bombing in April 1995 killed 170 innocent people. Armed paramilitary organizations, formed as a result of antigovernment sentiment, interpret the U.S. Constitution for themselves. In effect, they claim liberty as their exclusive right, which sometimes includes the right to attack violently the objects of their hate. The existence of independent armed militias, sometimes filled with white supremacist rhetoric, could threaten the peaceful conduct of government and public business. These militia often identify the government itself as the enemy. By contrast, the mission of state-sponsored militia of the colonial period was in part to subdue armed insurrections against the state (Halpern and Levin 1996).\ SUMMARY\ It is often claimed that the United States has a crime problem. We do, but our crime rates, as determined by victimization surveys, resemble those of other high-income countries. It is often claimed that the United States has a violence problem. We do, but our violence rates resemble those of other high-income countries. What is out of line is our lethal violence, and most of our lethal violence is gun violence (Zimring and Hawkins 1997b).\ Over the past forty years, the increase in urbanization and the decline in hunting, combined with the fact that fewer adults live in each household, have resulted in a decreasing percentage of households with firearms. At the individual level, about 25 percent of adults currently own guns. On average, these individuals own more firearms than in the past, and the guns are increasingly likely to be handguns. Compared to other high-income nations, Americans own more guns, particularly handguns. And, as we shall see, these guns are readily available to virtually anyone who wants one.\ Chapter Two\ THE PUBLIC HEALTH APPROACH \ Assaultive injuries have been subjected to little prevention oriented research. Typically they have been regarded as a crime problem rather than as a health problem and blame and punishment of the perpetrators have been emphasized rather than measures to reduce the frequency and severity of such injuries. -Institute of Medicine, 1985\ During most of the twentieth century, gun assaults were seen almost exclusively as a criminal justice problem, gun suicides as a mental health problem, and unintentional gunshot wounds as a safety issue. Since the mid-1980s, it has become increasingly recognized that the most promising approach to reduce firearm injury is to emphasize prevention, focus on the community, use a broad array of policies, and bring together diverse interest groups. This approach is proactive rather than reactive, is pragmatic rather than doctrinaire, and has a distinguished history of success in addressing problems that affect the public's health-it is what I refer to throughout this book as the public health approach. This chapter describes the public health approach to reducing the firearm injury problem in the United States and the history and scientific basis of injury prevention and control as a public health field (Hemenway 1995). The chapter also contrasts the public health approach with the gun advocates' dichotomous view of a world inhabited solely by "good guys" and "bad guys" and explains why the public health perspective leads to more effective policy prescriptions.\ WHAT PUBLIC HEALTH MEANS IN PRACTICE\ The proactive, community-oriented approach of public health can be contrasted to the often reactive, individual focus of therapeutic medicine and traditional criminal justice. Medicine's principal focus is on curing the individual patient, one person at a time. Medical care providers across the country treat gunshot victims and their families on a daily basis, usually in humane and often heroic ways, but they do so one patient at a time.\ Similarly, the law enforcement and criminal justice systems seek to apprehend and punish those committing crimes, one perpetrator at a time. Although deterrence is an important goal of the criminal justice and tort systems and prevention is increasingly seen as a police function, most of the activity still takes place after the fact. By contrast, the goal of public health is neither to determine fault nor to punish perpetrators. Instead, public health focuses directly on prevention-eliminating the problem before something bad happens.\ The scientific core of public health is epidemiology, which identifies the risk factors, trends, and causes of health problems. But sound science is the starting point, not the end point, of the public health approach. Rallying political and social support around solutions is the way public health has achieved many of its goals.\ Perhaps the most important public health advance of the nineteenth century was the "great sanitary awakening" (Winslow 1923), which identified filth as both a cause of disease and a vehicle of transmission. Sanitation changed the way society thought about health. Illness came to be seen as an indicator not of poor moral and spiritual conditions but of poor environmental conditions. Public health interventions began to emphasize the need to change the environment as well as individual behavior.\ Early efforts to combat tuberculosis, for example, succeeded primarily because they addressed poor sanitation and overcrowding in urban neighborhoods rather than because of individual medical treatments (Haines 1997). The knowledge that social and environmental conditions could cause disease and the identification of societal actions that could dramatically reduce outbreaks meant that health could no longer be considered solely an individual responsibility. Public health came into its own.\ (Continues...)\ \ \ \ \ Excerpted from PRIVATE GUNS PUBLIC HEALTH by David Hemenway Copyright © 2004 by David Hemenway. Excerpted by permission.\ All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.\ Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site. \ \

PrefaceCh. 1Guns and American Society1Ch. 2The Public Health Approach8Ch. 3Gun-Related Injury and Death27Ch. 4Self-Defense Use of Guns64Ch. 5Location79Ch. 6Demography107Ch. 7Supply130Ch. 8Policy Background152Ch. 9Policy Lessons177Ch. 10Policy Actions209Conclusion224App. A: Methodology227App. BFamous Civilians Shot in the United States253Bibliography255Name Index301Place Index311General Index315

\ From the Publisher"Diagnosing and treating the gun violence epidemic demands . . . public health solutions in conjunction with legislative and law enforcement strategies."\ —-Kweisi Mfume, President and CEO, National Association for the Advancement of Colored People\ ". . . essential reading for anyone who wishes to understand the tragedy of gun violence in America. . . ."\ —-Richard North Patterson\ \ \