The Facts About Firearms Injury
ABSTRACT&COMMENTARY
Source: Kellerman AL, et al. Injuries due to firearms in three cities. N Engl J Med 1996;335:1438-1444.
A population-based study of firearm injury in three cities in the United States, supported by the CDC, has been reported by Kellerman et al. This study, unique in its comprehensive view of firearms injury, is not merely another case series of admitted patients from a trauma center or fatal injuries from a medical examiner database. The authors linked data on firearm injuries from a number of data sources: police reports, emergency medical services, hospital emergency departments, and medical examiners’ records. The use of these linked data allows conclusions to be drawn about the true circumstances of injurywho is injured, what injured them, when, where and how the injuries occurredall of which are essential to understanding the problem so that injury prevention strategies can be designed.
The cities of Memphis, Seattle, and Galveston were chosen for study; these cities differ in demographics such that comparisons of ethnic and social characteristics could be made. Census data were used to characterize the populations, and permanent residents of each city were eligible for inclusion in the study group. Cases were identified through any of the data sources; both hospital and police records were examined to delineate the circumstances surrounding the injuries.
A total of 1915 cases were identified and studied. Crude rates of injury from firearms per 100,000 population were 222.6 in Memphis, 143.6 in Galveston, and 54.1 in Seattle. The relative similarity of the rates when adjusted for age, sex, and race demonstrates the strong relationship of these social characteristics to firearm injury: 155.6 in Memphis, 160.0 in Galveston, and 110.2 in Seattle. These adjusted rates do not account for household income, but Memphis and Galveston have twice the percentage of the population below the federal poverty level compared to Seattle.
Blacks had 13.5 times the rate of injury of non-Hispanic whites; Hispanics had 2.6 times the rate of other whites. Males were shot 8.2 times the rate of females. Black males 15-29 years of age were injured 25 times as often as non-Hispanic whites of similar age.
Unintentional (a.k.a. "accidental") shootings accounted for only 4.5% of the injuries and 1.4% of the deaths. Most of these victims (78%) shot themselves, and in 89% of the cases, the gun was a handgun. Nonfatal injuries outnumbered deaths 16 to 1. In contrast, assaults accounted for 78% of the injuries due to firearms, and 65% of the deaths. Death occurred in 16% of firearms assaults. Handguns were used in 89% of cases where the weapon was documented. Suicide was the most lethal, accounting for only 7.2% of injuries but 33% of the deaths. Handguns were used in 85% of suicide cases.
This study conclusively supports information that has been pieced together from multiple earlier studies within medicine and the criminal justice system. Firearm injury is a major public health problem in urban areas in the United States. Young black men are being killed and injured at rates incredibly disproportionate to the rest of the population. Assaults are the source of most gunshot wounds, although suicide attempts are the most lethal. Fatality rates are lowest for accidental injury. Handguns are disproportionately involved: 80-90% in all communities studied.
COMMENT BY JEFFREY RUNGE, MD
The importance of population-based research to the understanding of injury and other diseases cannot be overestimated. In addition to the important conclusions generated by this study, the authors’ use of linked data to elucidate the characteristics of this particular injury type sets a new standard for injury control research. Knowing the population, causes, place, time, and circumstances of injuries enables communities to target resources more effectively to prevent injuries. These same principles of disease control have been applied to infectious disease and cancer for decades. Fortunately, injury is finally becoming recognized as an illness, which, like any other, is amenable to the same methods of prevention. Only through comprehensive research and targeted disease control will we make a dent in this enormous public health problem.
As with many epidemiologic studies, this study poses many more questions than it answers. Why are young black males more prone to be victims of violence than any other group? What differences exist between the victims and the perpetrators? Were the suicides premeditated or impulsive, and did the availability of a gun increase the gun suicide rate? Can the design of the gun be attributed to the 78% of accidental gunshot wounds that were self-inflicted? How does poverty interact with the high rate of gun-related injuries among minority groups? Are these populations amenable to public education interventions? Are laws and their enforcement effective deterrents to firearm assaults?
It seems that the questions and answers are complex and can only be addressed with more research in this area. The CDC’s efforts to address firearm injury as a public health problem should be commended, even as our culture is hesitant to address this issue. The human primordial fascination with harnessing kinetic energy for its own purpose is never more evident than in its fascination with firearms. Fortunately, we have engineered energy containment so that we don’t have to get burned to stay warm or injured to transport ourselves rapidly. Perhaps we can evolve socially so that firearms will no longer be perceived as necessary to achieve dominance or protection. Until that time, we will seek to understand this phenomenon that adversely affects the health of citizens so profoundly.
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