Thank you to SCCM for this opportunity to talk about the epidemiology of violent injury. My name is Eleanor Kaufman. I'm a trauma surgeon at the University of Pennsylvania and a health services researcher focused on these issues. I don't have any financial conflicts of interest to disclose. I do have relevant funding related to hospital-based violence intervention programs from the Eastern Association for the Surgery of Trauma and the Pennsylvania Commission on Crime and Delinquency. And I do think it's fair to say that I think that there's a good deal of evidence to underlie my belief that the harms of living with firearms as individuals, families, or as our society outweighs their benefits. I'm going to talk a little bit about the epidemiology of violent injury in the United States, a little bit about selected international comparisons, and highlight some important knowledge and data gaps. And also hopefully talk about some examples of prevention interventions that hold promise or are effective. So just beginning at the beginning, this is a summary from the CDC of all violent deaths in the year 2020, and we see that firearms account for 62% of these, followed by suffocation. When we look at homicides, there were 25,356 deaths, accounting for nearly 800,000 years of life lost from homicide in the United States in 2020. Nearly 80% of these involved a firearm, followed by cutting or piercing at a distance. Suicide breaks down a little bit differently. This is the most common form of violent death in the United States, accounting for 45,979 years of life lost, nearly a million years of potential life lost in that year. Firearms account for the majority of suicides, followed by suffocation, or unfortunately hanging in that case, and overdose. And when we talk about suicide, it makes a big difference to talk about the means. Firearms are not the most common means of suicide attempt, but as you look at these bars appearing here, they are by far the most lethal. So that unfortunately, up to 90% of suicide attempts that involve a firearm result in death. And that is really important because of this other 10%. Of people who survive an initial suicide attempt, only 10% later go on to die by suicide. And this is because there may be long-term mental illness or psychological distress that leads to this suicide attempt, but the actual suicidal impulse is often very short-lived. Two-thirds of suicidal impulses last less than one day. And that means that if we can separate someone from lethal means, we may not always prevent a suicide attempt, but we can save a life and get that person the opportunity for care and treatment that they need to join that 90% of long-term survivors. And this is why I think it's really important to talk about secure storage of firearms, the same way we talk about secure storage of medications. The safest way to secure a firearm is locked and unloaded, separated from ammunition and inaccessible to children. This is essential for preventing suicide, particularly youth suicide, and also for preventing unintentional injury and death, especially in children. Secure storage can look different for different people, may look like a lockbox or a safe or a lock, a cable lock like this or a trigger lock. And it helps, like I said, with suicide, with unintentional injury. It also indirectly can help with firearm assault and homicide, in part because secure storage can prevent theft and diversion of firearms into the secondary. But the use of secure storage is far from where we want it to be. Overall, about 45% of firearms are stored securely. And unfortunately, in households with children, it's not that much better, leaving plenty of room for improvement. This is an angle on which, as healthcare providers, we really have the opportunity to act. Patients and families are receptive to talking about these issues. They are receptive to receiving secure storage devices from their healthcare providers. And this is really an opportunity for us to provide that type of guidance and support to our firearms. Means matter when it comes to interpersonal violence as well. We've been talking about firearm injuries, and the majority of firearm injured patients do survive. About three quarters of them survive, right? Stabbings are actually more common in the United States. These data are old, but there were about twice as many stabbings in 2014 as there were shootings. But look at those numbers of death. It's just a tiny, tiny wedge, right? That brings us to a couple of international comparisons that I think are illustrative. So the blue piece of these bars for all these different countries are their firearm homicide rates. The red is homicide by all other means. And just think in your mind for a second what the United States is going to look like compared to this relatively wide range of developed countries across the world. It's not the same, right? So that red bar, the non-firearm homicides, is not too different from what you see in some of these other countries like Hungary and the Czech Republic and Finland and even Korea, right? But that blue section of the bar really drives our overall homicide rate dramatically out of the proportion with some of the countries that we might like to be compared to. You may remember hearing about an epidemic of knife violence and crime in the United Kingdom over the last couple of years. And it's an interesting story that I think speaks to some of what we know and what we don't know about violence and injury in both of these countries. So there was about a 20% increase in violent crime recorded by the police, specifically knife crime was up about 7% in that time period, 2017, 2018. And a lot of consternation nationally in the UK about increased violence. But largely this was based on police crime data and the size of the increase really varied depending on the reference period and the definition of violence. Well, these are figures taken from my colleague David Humphreys, who found that over the same time period, emergency department visits for violence-related injuries or hospital admissions related to assault didn't show any increase and neither did homicide. So it turns out that this story is a lot more about data and data collection than it is about real changes in patterns of violence in the world. During the same time period, media reports related to violent injury in the UK and to knife crime and stabbings in specific skyrocketed. And what we see here is the ratio of crimes reported to injuries reported. And you see that for several years, basically the whole first decade on this graph was less than one. So there were assault-related injuries and no corresponding violent crimes for some segment of the injured population. And then that ratio reverses and actually gets up much higher so that more crimes than injuries are being reported. And this has to do with changes in reporting policies for the police who could report crimes, how exactly violence was defined, but not actually a change in the number of injuries or necessarily violent incidents. So I think those international comparisons give some credence to why it is so important to talk specifically about firearms and firearm-related injury, at least here in the United States, Our firearm ownership stands in dramatic contrast to many of our comparator countries. The United States has dramatically more firearms among civilians than the next closest country, right, which is Yemen. About 30% of individuals in the US own at least one firearm, accounting for about 40% of households, 393 million firearms in the United States, more firearms than people. And over the last couple of years during the COVID pandemic, about 7.5 million new firearm owners bought their first firearm, exposing 16 million new people to firearms in the home. The most common reason for owning a firearm is protection, specifically fear of other people. This is troubling for so many reasons, including that unfortunately the research does not really support this practice so that people who live in a home with a gun are at about two times the risk of homicide in study after study over the last several decades, about three times the risk of suicide. If there is an assault, they are about five times more likely to be shot because the presence of one gun and the presence of a second gun tends to lead to escalation and the risk of intimate partner homicide goes up by about one. This is an example of a, taken from the news of a patient who is not my patient but could have been, that really puts, I think, a different angle on what it means to own a firearm protection. This young man actually does live with a real risk of firearm violence and at age 13, he saw his father murdered during a home invasion and he was scared and as soon as he could, he bought a gun at a gun show, he slept with it under his pillow and he carried it with him, including when he was talking with a friend outside a laundromat. Three men approached and he had the feeling that they were going to rob him. He pulled his gun and tried to shoot but somehow in that process, someone shot him and he became an ICU patient like many of us have taken care of. So firearm injury really does affect all of us but as that story kind of starts to illustrate, the effects are not distributed evenly. There are about 100 deaths per day. In 2021, we saw the highest total number of deaths on record, making firearms now the leading cause of death between ages 1 and 19, accounting for $410 billion in medical costs, loss of work, quality of life, etc. But the risk is not equal, right? So we have here homicide across the top, suicide across the bottom, men on the left and women on the right and we see that by far the highest rate of firearm homicide is among young black men and boys, up to nearly 80 per 100,000 per year. The pattern in suicide is quite different with the highest rates being among older white men, followed by younger Native Americans and to some extent younger black men as well. The shape of these graphs is very similar between men and women, but the scale is off by about a factor of 10. None of this is getting better, unfortunately. Suicide rates have been rising for nearly two decades at this point. Homicide rates have started to rise in the last several years, really beginning in 2016 and as you can see in these graphs, I hope, most of that rise in homicide is accounted for by the deaths of black men. And this is because firearm violence stands as a legacy of structural inequity and structural racism, which is the decades and in some cases centuries of systematic disinvestment in black neighborhoods and other neighborhoods and communities of color and disenfranchisement of black people and other people of color. This is just one example locally from where I am in Philadelphia in which you can see the historical housing discrimination redlining maps laid out next to the maps a hundred years later of where violence occurred. I do think police violence and police shootings deserve a special mention in the context of talking about violent injury and death in the United States. These are relatively rare deaths accounting for between 1,000 and 1,500 civilian deaths per year, but they have outsized importance in terms of how our society is structured. Black people make up about 12% of the population, but are doubly overrepresented among those killed, and even more so among unarmed and non-threatening cases of police shootings and death. The impacts of these deaths and injuries are broad. Personal experience of police violence for survivors increases risk of psychosis and suicide attempts. Police killings contribute to poor mental health of black people as far as the state level, and police stops even increase anxiety, PTSD, depressive symptoms, and can worsen neighborhood-level psychological distress, deter ED utilization, and increase mistrust even of medical institutions. We talked about deaths a fair amount, and we talked a little bit about survival rates, but survival is ... More than two-thirds of firearm-injured individuals survive. The majority of deaths in that blue color, once again, are suicides, but the majority of survivors are related to assault here in green and unintentional injury here in red. The impact of this kind of trauma is deep and wide. It's physical, it's emotional, it's social, and it affects individuals, families, and communities. Functional limitations are substantial. After injury, 40% are unable to return to work, 17% need help, 20% develop PTSD, 37% have new limitations in their ADLs. With functional limitations ... That's for all injury, but as you can see here, intentional injury is a substantial contributor to some of these limitations such as ... injury, leading to this kind of finding from colleagues of mine at Penn, looking at the proportion of firearm individuals up to six years after injury who have worse global physical health, mental health, physical function, emotional support, and ability to participate in social roles and activities compared to population. And I think one of the best studies that's been written on this is by Dr. John Rich, who talked about pathways to recurrent trauma involving the need to recover from a loss of respect, not in every case, right, but in some, lack of faith in police and other institutions, and trauma-related symptoms, the symptoms of traumatic stress that may increase people's need to self-medicate with marijuana and other illicit substances that may put them at risk for increased firearm carriage, hypervigilance that makes people jumpy and can put them at risk for injuring someone else or for being injured once again. I'm going to shift gears a little bit and talk about some strategies to address this before we finish today. There's no one solution, but there are many opportunities, and I think there's a lot of promising work out there that deserves our attention. A lot of the attention in this space has been paid to firearm policy specifically, and this is a nice picture from the RAND Corporation summarizing some of the evidence on firearm policies at the state level that have the potential to affect some of the outcomes we care about as far as violent crime, unintentional injuries and death, and suicide. But I'm always struck by the words of my mentor, Charlie Brenes, who is always telling us to look beyond firearm-focused policy, and I'm going to read a little bit right here from his work in JAMA Psychiatry last year, where he says, the public health, medical, and scientific research communities can no longer be at the mercy of U.S. state and federal legislators, simply waiting for them to successfully pass or repeal laws as the only source of scientific and policy innovation to prevent gun violence in the U.S. This is a weak and unidimensional forfeiture in the face of a complex and intransigent problem for which the U.S. public are rightly demanding innovative, effective, and immediate solutions, and Charlie really highlights some of the solutions that can address firearm violence and other violence through their root causes and the other benefits that some of those interventions can have. So every 10 additional nonprofit community-building programs are associated with a 9% reduction in homicide and a 6% reduction in violence. These can be community-led initiatives, youth development, career services, the arts, neighborhood interventions that have co-benefits that go beyond reductions in gun violence. With thoughtful implementation, they may also address the most basic upstream causes of gun violence, such as structural racism, poverty, housing inequity, unemployment, and educational inequality. And I'm just going to highlight a couple of things. Improving access to green space and reducing vacant lots has been shown to reduce neighborhood perceptions of crime, safety concerns, crimes, gun assaults, and depression, particularly in neighborhoods below the poverty line, and this is a randomized community trial. There are similar findings related to remediation. We talked about the impact of trauma and firearm injury on survivors. Providing focused support through hospital-based violence intervention programs improves patients' recovery, reducing their subsequent misdemeanors, aggression, violent crime, improving self-efficacy, decreasing substance use, and in several randomized controlled trials has been shown to decrease recurrent injury. Cure violence is the most common form of what's known as violence interruption, in which trained credible messengers are deployed to communities at risk to diffuse conflict and to promote peaceful resolution, and this has been associated with substantial decreases in homicide and violent crime. Peacemakers Fellowships are a form of focused intervention that works with high-risk individuals to provide them the support and resources they need to overcome. I'm going to go back again to suicide, which is the most common form of violent death and firearm-related death in the United States, to say that there are counseling interventions, there are secure storage interventions that we mentioned, there are extreme risk protection orders which temporarily separate high-risk individuals from lethal means, temporary storage programs like this one in Colorado, which identifies locations that will store your firearm for you, as well as waiting periods and licensing laws that can make a difference. We also talked about police shootings, so I think it's important to talk about some of the evidence-based strategies that can reduce this as well, including ending low-stakes broken windows policing, improving community oversight, limiting use of force, and improving oversight and training. So in closing, I just want to say that firearm injury and all-violent injury really is prevalent, is harmful, but is eminently preventable. When we think about gun violence, we can think about the guns, but also about the violence and its root causes. The long-term impacts are poor, but the solutions are numerous and include everything from the environment to engineering to economic interventions, collaborating across disciplines and aisles, and often involve identifying and intervening with those who are at highest risk to provide the safety mechanisms, the resources, and the support that they need to be safe. Thank you again for your attention. Enjoy the Congress.

violent injury

firearms

suicides

firearm-related deaths

firearm violence

police violence