Firearm injuries and death: A United States epidemic with public health solutions

Firearm injuries and death are an eminently preventable public health epidemic in the United States (U.S.). Globally, for the last several decades, U.S. firearm homicide rates far outpaced those of other high-income countries, with more than 45,000 people killed by firearms in the U.S. in 2020 alone–greater than in any previous year on record [1,2]. U.S. children are 11 times more likely to die of a firearm injury than children in other high-income countries [3], and firearm injury is the leading cause of death for Americans age 1–19 (largely due to homicide) [4]. This epidemic also has a disproportionate impact on people who are Black, Indigenous and/or people of color (BIPOC), especially in socially vulnerable, underserved communities. Firearm homicide is the leading cause of death for Black males 15–34 years old, and Black men are 10–20 times more likely to be killed by a gun than White men [1]. American Indian and Alaskan Native men are 3–4 times more likely to die by firearm suicide than White men [2].

Despite the growing frequency of school shootings and public mass shootings in the U.S, mass shootings in schools and other public spaces make up a minority of U.S. firearm injuries and deaths [1]. Instead, most U.S. firearm deaths are homicide and suicide. Indeed, firearms are the most common mechanism by which U.S. adults and children die from suicide, with approximately 53% of suicide deaths resulting from firearms in 2021 [1]. Firearms are also the most common mechanism of homicide, causing 80% of U.S. homicide deaths in 2021 [1]. Intimate partner homicide is most frequently completed with firearms in the U.S. [2]. Most non-fatal firearm injuries are due to assault [1].

The impact of these violent injuries on individuals, families, communities and U.S. society is massive [5], ranging from anxiety, to substance use, to increased firearm purchasing. Studies suggest a strong, but not complete, correlation between rates of firearm ownership and number of firearm deaths [6]. Other causes of injury and death are also at play. For example, underinvestment in the physical structure of a city has been shown to influence rates of firearm ownership and death. Firearm ownership practices related to beliefs around the need for self-protection may contribute to unintentional injury rates. A history of firearm trauma–and resultant patterns of post-traumatic stress, substance use, involvement in the criminal justice system, and carrying firearms for self-protection–may lead to perpetuating cycles of firearm injury and death [7]. Structural racism, which includes residential segregation, low-quality schools, limited healthcare resources, and lack of implementation of effective criminal justice policy, further contributes to adverse social determinants of health that increase risk for firearm assault [8].

Firearm injuries—regardless of intent—are influenced by multiple levels of the social-ecologic model, which makes legislation in isolated states or regions a challenging mode of intervention when used in isolation [5]. Unfortunately, since the mid-1990s, federal funding and legislation addressing firearm injury as a public health problem has lagged far behind the burden of this disease [9]. In parallel, the U.S. has become a global leader in population adjusted rates of firearm ownership (access) [10]. Approximately 400 million firearms are owned by U.S. private citizens [6], and millions of Americans became first-time firearm owners during the COVID-19 pandemic.

Yet all hope is not lost.

The field of public health is well positioned to contribute many actionable solutions that are ready to be deployed and scaled. Solutions to any public health epidemic must be multi-factorial, including economic, structural, legislative, and educational interventions–and solutions to the problem of firearm violence are urgently needed.

Recent systematic reviews have evaluated broad classes of gun legislative polices that have been implemented in some U.S. states [11,12]. Policies correlated with reduced suicide, violent crime and homicide rates include minimum age requirements, prohibitions associated with domestic violence, surrender of firearms by prohibited possessors, background checks, and waiting periods. Child access prevention laws—also known as safe storage laws—appear to be among the most effective. Such laws, which require guns to be stored locked, unloaded, and kept apart from ammunition, correlate with reduced suicides and homicides among young people [12]. Extreme risk protection orders (“red flag laws”) are also promising tools to reduce firearm suicide and mass shootings. However, the current U.S. political environment and the recent Supreme Court Bruen decision limit both legislation and its enforcement, on both the state and federal level. Moreover, the history of public health teaches us that legislation alone rarely solves a public health problem.

A promising public health concept is that of harm reduction. Harm reduction is a comprehensive prevention strategy that emphasizes engaging directly with people at risk for harm. This strategy offers low-threshold options to access prevention and treatment that facilitate individual autonomy, and improve physical and mental health and social wellbeing [13]. Harm reduction includes several core principles (Table 1).

Table 1. Core principles of harm reduction in the public health context.

Principle	Definition	Example of harm reduction-based strategy for firearm injury prevention
Humanism	We value, care for, respect, and dignify people as individuals. Understanding why people make decisions empowers change.	Collaboration with firearm owners is necessary to respect and dignify choices that may reduce (but not eliminate) risk of injury.
Pragmatism	None of us will ever achieve perfect health behaviors. Health behaviors and the ability to change them are influenced by social and community norms (i.e., behaviors do not occur within a vacuum).	Reductions in injury patterns will be enhanced by addressing the structural- and community-level drivers of injury.
Individualism	Every person presents with their own needs and strengths. People require a spectrum of intervention options.	Hospital-based violence intervention programs can provide social- and case-based services through individualized treatment plans.
Incrementalism	Any positive change is a step toward improved health, and positive change can take years. It is important to understand and plan for backward movements.	Safer storage of firearms lies along a spectrum from storing all firearms locked and unloaded, to storing all firearms unlocked and loaded.

Firearm injury prevention interventions well-aligned with the principles of harm reduction exist. For example, individual-level interventions such as counseling on access to lethal means (CALM) and anticipatory guidance on safe storage of firearms have the potential to decrease firearm deaths from both suicide and accidental injury [14]. Similarly, the American Academy of Pediatrics recommends “anticipatory guidance” around firearm storage, in which health care providers discuss safe firearm storage with parents of children and teens–similar to how they discuss bicycle helmets and access to medicines–to limit unauthorized access.

Another actionable, non-legislative, harm-reduction-centered approach to firearm injury prevention includes violence intervention or interruption programs, including hospital-based violence intervention programs (HVIPs), that address individual root causes of community-based firearm assault. Grounded in a peer support and case management model, these programs engage violent injury survivors in prevention efforts aimed at improving health and safety of patients and their families after hospital-based care for violent injuries. Used in concert with broad multidisciplinary strategies, HVIPs may contribute to lower reinjury rates after one year of program participation and mitigate the secondary effects of violence (e.g. post-traumatic stress disorder, long-term disability, missed school) [5,15].

Finally, collective prevention efforts are needed to increase community engagement and normative change. Several regional and national organizations are working towards this goal of equitable approaches and solutions that mitigate the undue burden of firearm violence, especially among our most vulnerable populations. For example, the Health Alliance for Violence Intervention builds and connects violence intervention programs and promotes equity for victims of violence globally. The community-based public safety (CBPS) collective is a recently emerged group of firearm violence prevention workers building capacity for research and advocacy to address community violence in Black and Brown communities by strengthening neighborhood leadership through investment in the education, advocacy and training of community-based public safety practitioners and organizations. The Penn Urban Health Lab has worked with local government and community organizations to understand the ways in which the physical attributes of where people, live, work, and play influence mental health, substance use, and violent crime. Through partnerships with 4-H, research is being conducted to evaluate the efficacy of bystander intervention curricula for youth in shooting sports programs. Hospitals (e.g., Northwell Health), health systems (e.g. Kaiser Permanente), and academic centers (e.g., University of Michigan) are investing in comprehensive firearm injury prevention collaborations and research.

There is great potential to successfully disrupt this U.S. crisis of firearm injury and death. To attain this goal, however, substantial intentional investment in research, programming, personnel, policies, and community infrastructure is needed. We remind readers, however, that public health professionals, health care providers, and community members can make a difference, regardless of politics. We can collect data, implement evidence-based programs, advocate for evidence-based policies and regulation, and work to shift culture and reduce harm—today.

Funding Statement

This work was supported by the Centers for Disease Control and Prevention (CE003267 to MLR) and the National Institute of Health (NIGMS P20 GM139664 to MLR, U54 MD002329 to NL, UL1 TR003107 to NL, and UAMS Translational Research Institute KL2 TR003108 to NL). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.