Past research has shown us that improving the safety of motor vehicles led to a drop in children’s car accident deaths. A new study in Pediatrics proposes that preventive policies directed at reducing gun injuries among children could likely lead to fewer deaths as well – and such policies are much needed considering the study’s main findings.

The study found that one third of the children who died from gunshot wounds died before ever reaching the hospital — and that one in every five children who were shot died.

The researchers examined all 9-1-1 calls related to children’s injuries in five geographical areas to assess how firearm injuries compared to other types. More than 29,000 children under age 19 died from gunshots from 2001 to 2010, the authors noted.

Gunshot injuries accounted for only 1% of all children's injuries that were called into EMS -- but they accounted for one fifth of the deaths. Photo by Robert Linder

Gunshot injuries accounted for only 1% of all children’s injuries that were called into EMS — but they accounted for one fifth of the deaths. Photo by Robert Linder

There’s good news:

  • Following a peak in gunshot injuries in 1994, firearm deaths in children dropped by half (55%) by 2003.
  • The study found that firearm injuries accounted for only 1% of all the injuries to children leading to a 9-1-1 call.

But there’s bad news too:

  • Since that decline, firearm-caused death rates for children have stagnated since 2003.
  • 21% of the children in this study who died had been shot — making firearm deaths proportionally the highest death rate of all injuries.

Or, more plainly, kids who were shot were far more likely to die than kids injured in any other way.

Briefly, here’s how the researchers conducted the study: First they looked at all EMS and 9-1-1 calls coming in to 47 EMS agencies that serve more than 2.2 million children. The agencies cover emergency transports to 93 hospitals in the rural, suburban and metropolitan areas of five geographical regions: four counties around Portland/Vancouver on the Oregon/Washington border; King County in Washington; Sacramento, Calif.; Santa Clara, Calif.; and Denver County, Colo.

With this data, the researchers then determined what the injuries were for all children up to age 19 (a total of 49,983 children) calling in to those EMS centers. Then they compared the severity of injuries, major surgeries, blood transfusions, deaths and overall costs per child in each of six injury categories: gunshot, cut/piercing/stabbing, car accidents, getting hit by a car, falls, blunt objects and “other.”

Their main findings were sadly unsurprising: “Gunshot injuries were more severe, requiring more frequent major therapeutic interventions and resulting in higher mortality and per-patient costs than any other injury mechanism.” In fact, a child arriving at the hospital with a gunshot wound was four times more likely to die (8% in-hospital death rate) than a child coming in with the next most deadly injury, piercings and stabbings (2% rate).

Consider some of the specifics:
•    Children with gunshot injuries represented the highest proportion of severe injuries (23% of all the injuries categorized as most severe were due to firearms)
•    Abdominal/pelvic injuries and extremity injuries were proportionally far more common among gunshot victims than among victims of any other injury
•    One third of all the children who required major surgery (of total injuries) had been shot
•    Firearm victims were more likely than those injured any other way to need a blood transfusion

Although the rate averaged across all regions was 7.5 gunshot injuries per 100,000 children, the rates varied dramatically from one region to the next: from 2 cases to 31 cases per 100,000 children. The vast majority of gunshot injuries afflicted older teens, aged 15 to 19, who comprised 83% of all firearm injuries (though this age group only comprised 49% of total injuries of any kind). In addition, 84.5% of the firearm injuries occurred to males, though males were involved in only 59% of total injuries of any kind.

And getting shot is pretty expensive too. The highest per-patient average cost for any of the injuries was $28,510 — the average medical costs for treating children who had been shot. The next highest amount was for car accidents but was almost half as much: $15,566.

“These comparisons illustrate the immense per-patient impact of gunshot injuries in children,” the researchers wrote — yet these costs do not include any costs outside of the hospital. They do not include long-term outcomes, additional medical costs in follow-up or physical therapy, costs related to PTSD or other mental health repercussions, lost productivity in the children’s futures, lost productivity to society for the children’s deaths, lost productivity and related costs to the family, friends and other community members who grieved or were otherwise affected by these injuries and deaths, court costs in any cases that were filed as a result of the cases…

Like any study, this one throws a lot of numbers at us, but the big takeaway is pretty straightforward: firearm injuries may be relatively rare compared to other major injuries among children, but gunshots account for one in five deaths among children and have enormous personal, medical and financial impact.

But that does not mean the situation is hopeless. “Lessons in improving car motor vehicle safety (eg, booster seats, age-appropriate restraint systems and seat position, air bags) and the associated reductions in pediatric motor vehicle mortality provide important examples of the potential impact of injury prevention efforts,” the authors wrote.

If we can make it less likely for a car accident to kill children through smart, evidence-based policies, then we should also be able to develop smart, evidence-based policies that reduce children’s likelihood of dying from guns as well.

 

This study was funded by the National Institutes of Health, the Robert Wood Johnson Foundation, California Wellness Foundation, the Oregon Clinical and Translational Research Institute, the University of California Davis Clinical and Translational Science Center, the Stanford Center for Clinical and Translational Education and Research, the University of Utah Center for Clinical and Translational Science, and the University of California San Francisco Clinical and Translational Science Institute.

This is the key question so many of us involved in the gun debate face. On a personal level, answering it has big implications for our families’ safety. As Amy discussed in a recent post, having a gun in the household increases the chances that someone in the household will die by gunshot, though even in households with guns there are many things you can do to keep your kids safer.

US and Japanese Flags With GunBut what about across the country? At the national level, the question has big implications for our country’s laws. Many people carry concealed or unconcealed weapons in public places out of fear of crime. Some people argue (see, for instance, here) that laws that allow easy access to guns and that allow guns to be carried in public places in the United States help to keep crime rates down. A recent study in The American Journal of Medicine – one of our country’s most prestigious sources of cutting-edge research in medicine and public health – concludes that that the answer is decidedly “No.”

The authors of this study examine rates of firearm ownership in 27 developed countries: from culturally relatively similar ones like Australia and New Zealand, to culturally quite different ones such as Japan. They also consider rates of major depressive disorder in those countries. Then they ask how firearm ownership and mental health problems in each country are related to the crime rate and the number of firearm deaths per person.

What they find is striking: the more guns in a country, the higher its rate of firearm deaths. The relationship is very strong, and holds up even when you don’t consider the countries at the extremes, such as the United States (high gun ownership, high firearm death rate) and Japan (low gun ownership, low firearm death rate). No matter how you slice the data, the more guns a country has, the more likely the average citizen is to die by gunshot. By contrast, there is a small, statistically significant relationship between mental illness and rates of gun deaths, but the association is very weak.

But some people might say that even if more guns means more gun deaths, criminals will be less likely to strike in countries where they fear that their potential victims could have a concealed weapon. In other words, maybe crime rates go down at the same time that would-be criminals are more likely to get killed. Unfortunately, once again the authors find that the answer is “No.” They find that there is no relationship between the number of guns per person in a country and the country’s crime rate. The U.S. happens to have a lot of guns and, in recent years, pretty low crime rates. But Japan has very few guns and even lower crime rates. And the UK and Israel have fewer guns than the U.S., but more crime.

Surely there must be some cases in which the presence of guns helps to prevent a crime, or in which potential victims kill would-be attackers. Still, this study has a very clear conclusion: on average and across the developed world, having more guns does NOT make countries safer.

Mass shootings are so common now that many aren’t even mentioned in national news media. We decided to keep a watchful eye one weekend, not to note every shooting (that would be an enormous undertaking), but every shooting involving multiple victims. Surely we’ve missed some. In addition to the 13 incidents on this infographic, we found several more, all from this weekend: two people were shot in Brooklyn NY; two in Lackawanna, NY; two in Buena Vista, MI; two in Union City, CA; two in Syracuse, NY; two in Jacksonville, FL; three in Rochester, NY; three in Asbury Park, NJ; three in Portland, OR.

multiplevictims5

One argument we’ve seen ad nauseum is that Chicago has extraordinarily high violence due to its gun control laws. It’s true that Chicago’s homicide rate is higher than some other cities (Chicago has 6.4 homicides per 100,000 people, whereas New York has 4.5). There are so many variables affecting violence that we’re not sure how anybody could say conclusively how Chicago’s crime rates are affected by its gun control laws–especially since the city and the state have porous borders through which people can easily bring guns from neighboring jurisdictions. But what we CAN say conclusively is that Chicago is NOT EVEN CLOSE to having the worst violence in the U.S.

Chicago3

Young people between the ages 14 and 24 in the U.S. die from firearm-related murders at 42 times the rate that they do in nearly two dozen other developed countries. In other words, if you’re between the ages of 14 and 24 and you live in the U.S., your chances of being killed with a gun are 42 times higher than if you lived in most other developed countries. A recent study in the medical journal Pediatrics looked at how many youth who go to the ER as a result of gun violence own guns themselves — and where they get their firearms.  Many of the findings of the study may not seem surprising — more firearm victims also owned guns, and most of the guns were obtained illegally. Still, more of this kind of research is necessary to learn the best policies that might eventually help reduce gun violence.

Photo by Guidonz at sxc.hu.

Photo by Guidonz at sxc.hu.

Such research on firearm injuries had been banned until the Obama administration removed a 17-year-long moratorium on firearm injury research. Hopefully this study is one of many more to come that can provide policymakers with a stronger evidence base for using research-based approaches to reducing gun violence.

The researchers, led by Dr. Patrick Carter at the University of Michigan Injury Center in Ann Arbor, surveyed 689 youth who came to the emergency department in Flint, Michigan with injuries related to assault (excluding child abuse, suicide attempts and sexual assault). The patients were all 14 to 24 years old, and the survey questions asked about the patients’ characteristics, firearm ownership, attitudes toward aggression, substance use and past history of violence.

About a quarter of those surveyed (23%) said they had carried or owned a firearm within the past six months, but only 17% of those with guns had gotten the gun legally. About 17% said they got the gun from a friend and 17% said they paid cash, and about half the youth said it would not be difficult to get a firearm. Among the youth who said they had carried or owned a gun, one in five had an automatic or semi-automatic weapon.

Given the number of youth in the study who had gotten a gun from a family member or friend, Dr. Robert Sege at the Boston University School of Medicine wrote in an accompanying editorial that the study’s findings provide reasons to follow the American Academy of Pediatrics recommendations regarding firearms: “that there should either be no guns in the home or, when that is not possible, the gun(s) should be stored unloaded and locked, with ammunition locked separately.”

The youths’ most commonly cited reason for carrying a gun is a familiar one: more than a third (37%) said they had the gun for protection. “The perceived need to own and carry firearms for protection among respondents with assault injury suggests a need to address youth’s perceived and real feeling of safety through individual and community intervention,” the authors wrote. Other reasons included “holding it for someone” (reported by 10% of those with guns) or having one because their “friends carry guns” (reported by 9%).

When the researchers looked at other characteristics of the patients, they found several patterns: the gun owners were more likely to be male, to use illegal drugs and to have been in a recent serious fight. For example, 40% of the gun owners binge drank, compared to 27% who didn’t own guns, and 67% of the gun owners used illegal drugs, compared to 49% of the non-gun-owners. White and black youth were equally likely to have guns, and higher income youth were more likely to have guns.

Most youth in both groups had been in serious physical fights in the past six months (86% of gun owners and 80% of non-gun-owners), but more than twice as many of the gun owners had caused an injury that required medical treatment. While 21% of non-gun-owners had caused such an injury in the past six months, 46% of the gun owners had. There were also high rates of intimate partner violence in both groups: 76% of youth who owned guns and 64% of those who didn’t reported violence with their romantic partner.

Those who had owned guns were also slightly more likely to have an aggressive or vengeful attitude, which is important “because health behavior models, which are key to many violence prevention efforts, suggest the first step to decreasing future aggression would be to modify aggressive attitudes.”

Unsurprisingly, those who owned guns were more likely to have been previous victims of gun violence (21% compared to 15%), to have been previously threatened by a gun (56% compared to 33%), to have pulled a gun in a fight (22% compared to 1%), or to have used the gun in a fight with someone they were dating (6% compared to 1%). However, one interesting finding was that only 3% of the youth in the whole study were involved in a gang, which included 9% of those who owned guns and 1% of those who didn’t.

The authors noted that their findings reveal how a gun owned reportedly for “defensive” purposes can also end up being used for non-defensive purposes. “Taken together, these findings demonstrate that even if the main reason youth reported that they obtained a gun was for protection, they are often both carrying and using the weapon,” the authors wrote. “In combination with high rates of substance use reported before the altercation, and higher rates of substance use seen in youth with firearms, this is particularly concerning for inadvertently increasing the risk of a firearm moving from a protective device to impulsive use and lethal outcomes.”

In his editorial, Dr. Sege pointed out the frustrating reality that great strides have been made in children’s public health when it comes to decreasing kids’ exposure to cigarette smoke, reducing lead poisoning in children, reducing kids’ car accident deaths and increasing efforts to address childhood obesity — yet “our failure to develop a public health response to gun deaths stands out as a unique exception.”

Dr. Sege notes one major reason for this lack of progress relates to the strangled research on gun injuries: only about $102,997 of the CDC’s $6.5 billion budget of the past three years has been devoted to firearm injury prevention. Insufficient funding has a predictable effect: “According to a study commissioned by Mayors Against Gun Violence, the volume of academic research on firearms violence has dropped by 60% since 1996, now accounting for only 30 articles per million academic publications,” Dr. Sege notes.

The Obama administration has pledged $10 million for the CDC to conduct further firearm injury research, but in the current funding climate it remains to be seen whether the funds are actually restored. If they are, the subsequent research and increasing awareness of gun violence as a major public health concern will hopefully push sensible, evidence-based firearm-related policies higher on legislative agendas.

These infographics attempt to illuminate the complexities of ammunition, in the interest of informed debate about possible new legislation and regulations.

Bullet_SizesINFO4s

The policy proposals that President Obama announced on Wednesday (organized by category here) outlined a wide-ranging agenda, including twenty-three items that could be implemented through executive action and twelve recommendations for action from Congress.* The items are a mixed bag, ranging from immediately actionable ideas to proposals that may never make it through Congress. Some are vague (launching a national dialogue about mental illness) while others are very specific (confirming a director for the ATF).  In the coming weeks, PAGV will explore, seek input on, and respond in detail to the specific items. Here we outline a few of our immediate reactions as parents and concerned citizens.

  1. This is an important first step. It is gratifying to see the President both take direct action on a number of important gun-related matters, and publicly initiate the conversation about what needs to change to address the ongoing epidemic of gun violence in the United States.
  2. We strongly agree with the need for a comprehensive legislative and executive agenda, one that attempts to solve gun violence by addressing gun access, gun safety, school safety, societal factors, and mental illness.  Reducing the threat of violence to our children will clearly require such a broad-based, comprehensive effort. Any flaws in individual proposals do not invalidate the entire effort.
  3. There will be something for everyone to like, and for everyone to hate, in the proposals.  Given the current political climate, this may be inevitable.  Due to the absence of thorough research into the causes and effects of gun violence, there is little agreement about its remedies, beyond a desire to see it end.  To some, allocating $10,000,000 to research the connection between video games and violence seems like the worst kind of pandering to the NRA’s “it’s-everything-but-the-guns” narrative. To others, requiring background checks on all gun sales seems like the first step in a government takeover.
  4. Some of the proposals concur in fundamental ways with recent policy proposals from Parents Against Gun Violence. One of the executive orders, for example, directed the Centers for Disease Control to initiate research into the health effects of gun access (PAGV Policy Plank #2, Empower Researchers), while a proposal to Congress urges legislators to allocate $30,000,000 for schools to develop emergency-response plans (Policy Plank #5, Protect Schools).
  5. While President Obama implemented a number of executive actions, the biggest proposed changes will all require legislative action. All of the major funding allocations (with the exception of $20 million to encourage states to share background data) also have to go through Congress. In the coming weeks, concerned parents and citizens need to make sure that our voices and perspectives are heard in the legislative debates.

* Note that Obama actually signed only three executive orders (technically “presidential memorandums“) on Wednesday.  The 23 “executive actions” named in the Obama proposal describe general policy priorities that would not require Congressional approval for implementation. However, many of the proposed “executive actions” come far from implemented (or implementable) public policy at this point.

logo2Parents Against Gun Violence was founded by a nationwide coalition of mothers and fathers hours after the Newtown, CT killings.  In the weeks that followed, our members were busy collecting and studying scientific, peer-reviewed research on the causes of gun violence and gun accidents, and strategizing about how to reduce both.

At the same time, we have engaged in intensive dialogue with concerned citizens from across the political spectrum.  Through this process of research and dialogue, we have developed a set of five policy planks that we believe can gain support across the political spectrum, and that provide a comprehensive approach to reducing gun violence. We encourage all concerned citizens to contact their representatives, senators and any other elected officials as well to advocate for these policy proposals. If you would like to sign the petition promoting this platform, click on the Change.org petition here.

As parents, we urge lawmakers and the President to consider the following:

Policy Plank 1.) Empower law enforcement

a.) Approve Andrew Traver, President Obama’s nominee for Director of the Bureau of Alcohol, Tobacco Firearms and Explosives.  Without a leader, the Bureau is hampered in its ability to enforce its congressionally mandated responsibilities, such as investigating and prosecuting straw purchasers who buy guns for criminals. More »

We’ve been covering a lot of medical association news related to the Newtown shooting and gun-related legislation, but that’s because we’re very focused on looking at what research can tell us about reducing firearm injury, and medical associations are closely involved with much of this research.

Just as the American Psychiatric Association issued their remarks last week, the American Academy of Pediatrics sent their own letter, which you can download here, to President Barack Obama and Congressional leaders on December 19.

The organization had published a report on firearm-related injuries affecting children in their journal Pediatrics in October, in which they wrote “The American Academy of Pediatrics continues to support a number of specific measures to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on semiautomatic assault weapons; and the strongest possible regulations of handguns for civilian use.”

Unsurprisingly, in their letter to political leaders, they were just as direct regarding policy proposals related to gun control, mental health and children’s exposure to violence:

•    ”New federal firearms legislation that bans assault weapon sales and the sales of high capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases and promotes strict gun safety policies is a necessary first step.
•    Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.
•    Finally, we must engage in a national dialogue designed to reduce children’s detrimental exposure to violence in their communities, environments and entertainment.”

We’ll be revisiting the full account of their policy report on firearms for a later blog post, but we also wanted to mention another article with similar recommendations. “Weapons of Mass Destruction,” published in the Archives of Internal Medicine, which is published by the American Medical Association, also offered commentary related to firearm regulation. More »

In the wake of the Newtown shooting, several medical organizations have spoken up about either gun violence itself, firearm safety or about the response of other organizations, such as the NRA.

Since much of the nationwide dialogue after this tragedy has involved discussions on mental health, it makes sense that the American Psychiatric Association issued their remarks. Dilip Jeste, MD, president of the APA, sent a letter December 20 on behalf of the organization to Senate Majority Leader Harry Reid, Senate Minority Leader Mitch McConnell, Speaker of the House John Boehner and House Minority Leader Nancy Pelosi.

The letter, which you can download here, focused on two main points. First, as part of their responsibility to their profession, Dr. Jeste said “psychiatrists stand ready to do whatever we can to help alleviate the suffering caused by the tragedy and to help the survivors cope with life after a trauma of this unimaginable magnitude.”

But more importantly, Dr. Jeste followed that with a reminder that focusing too much on the mental condition of the shooter risks inappropriately increasing the stigma already associated with mental illness. “Stigma remains one of the greatest barriers to early identification, intervention, and treatment for Americans seeking help for mental illness, and we hope that Congress will avoid making generalized assumptions about persons now in or seeking treatment for mental illness,” Dr. Jeste wrote.

After noting that the “vast majority of violence” does not occur at the hands of individuals with mental disorders, Dr. Jeste said that those who do commit the crimes generally are not receiving adequate or appropriate mental health treatment. The statistics he notes are sobering: Public mental health spending has been reduced by $4.35 billion from 2009 to 2012, and 29 states have gotten rid of over 3,200 psychiatric inpatient beds since 2008.

He also brought up an issue which had been in the medical news recently related to doctors’ ability to discuss firearm possession and safety with their patients: “We are also profoundly disturbed by recent efforts in some states to curb or bar the ability of physicians, including psychiatrists, to prudently and confidentially inquire about the presence of firearms in the home when the behavior of their patients warrants such an inquiry,” Dr. Jeste wrote.

An article published in JAMA Pediatrics (formerly Archives of Pediatrics and Adolescent Medicine) provided the history of the Florida law that attempted to prevent doctors from speaking to their patients about firearms, concluding “Dialogue stemming from these questions will help families protect children from multiple forms of harm.”

A few days after sending that letter, the APA spoke up again to express their “disappointment” to the statement by the NRA and specifically the mental health stigmatization that NRA CEO Wayne LaPierre promoted with his comments. The APA wrote in their news release (pdf):

“The association objected to LaPierre’s assumption that horrendous crimes such as the one committed by shooter Adam Lanza are commonly perpetrated by persons with mental illness. In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are ‘so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,’ a description that leads to the further stigmatization of people with mental illnesses.”

Noting that “only four to five percent of violent crimes are committed by people with mental illness,” Dr. Jeste reminded the press that those with mental illnesses are rarely violent and are much more likely to be crime victims than crime perpetrators. Calling the use of the word “lunatic” by LaPierre “offensive,” Dr. Jeste said, “About one quarter of all Americans have a mental disorder in any given year, and only a very small percentage of them will ever commit violent crimes.”

The letter concludes with a statement from APA CEO James Scully, MD: “The idea that mental illness and evil are one and the same thing is simply a relic of the past and has no place in our public dialogue. People who are clearly not mentally ill commit violent crimes and perform terrible acts every day. Unfortunately, Mr. LaPierre’s statements serve only to increase the stigma around mental illness and further the misconception that those with mental disorders are likely to be dangerous.”