Gun-related mortality in children- seeing past geography

Firearms have become the leading cause of death in children.¹ While the pandemic may have contributed to firearm-related mortality exceeding motor vehicle crashes in 2020, the increase in pediatric mortality from guns began in 2013–4. There can be no solution to this problem without first better understanding the problem. The article by Price and Khubchandani appearing in American Journal of Medicine Open² provides an important perspective on the geography of this horribly sad statistic. Their data show a significant increase in age adjusted mortality of 30% from 2010 to 2019 and provide state-by-state changes. Twenty-six states have had increases in pediatric firearm mortality rates while only four states had declines. Eighteen states had too few cases to report changes.

Geography is a proxy for other factors including state government laws. In the current hyper-polarized political climate, there will be a tendency to judge states based on these results. But rather than look at these results as coming from “good” states and “bad” states, children could benefit from an approach that emphasizes improvement from baseline towards the goal upon which everyone can surely agree- reducing deaths of children from guns.

If we change the goal from one state being “better” than another to an emphasis on improving from baseline, then states can begin conversations with peers and colleagues who currently have low mortality rates. The idea of communicating with other entities who have more successful outcomes is well-known to health care professionals. When faced with sub-optimal outcomes, we interact with practices that have “best practice” models. Most practitioners are more than happy to hear about approaches that result in better outcomes.

Looking at the results from Price and Khubchandani, the eighteen states that had absolute low mortality rates in pediatric gun violence represent examples of the best practices for we can implement for our children. The four states with improvements are to be commended for reducing this needless cause of death in youths. The 26 states with increases over the past ten years need to be encouraged to determine how to stop this trend and achieve the reductions obtained by other states. Discussions between these 26 states with increasing rates of mortality and those states with decreasing or low absolute rates of death should be fostered and encouraged.

What can the agenda for meetings between states look like? Interventions to maximize gun safety can occur within the home, the community and at the level of governmental policy. Increased education and emphasis on storing guns securely would seem very likely to reduce unintentional deaths for families and visitors. The benefits of safety locks and loaded chamber indicators would similarly seem to outweigh any inconvenience. Community programs to promote education about gun safety could be implemented. To address risks of mortality from suicide, mental health resources need to be prioritized to identify young people at increased risk. While rare, pediatric homicides can be addressed by Red-Flag laws. States can access established guidelines from professional organizations^3,4 that provide these and other specific recommendations to minimize gun-related injuries and death.

For a problem this tragic, it would be overly simplistic to think that geography is the only variable to consider. While some shootings have occurred in states with increases in violence (Uvalde, Texas and Greenwood, Indiana), there are examples of shootings in states with overall decreases in violence (Buffalo, New York and Highland Park, Illinois). Of the ten states with the most school shootings,⁵ six had increased mortality rates over between 2010–2019 but four had experienced decreased rates of pediatric gun violence during that interval. Even after correcting school shootings per million people,⁶ only two of the five states with the most school shootings had increases in pediatric gun mortality from 2010–2019 by Price and Khubchandani.

Deadly shootings involving children are not exclusively defined by state borders. Beyond what states can accomplish, we need to consider possibilities including cooperation between states or national oversight programs. Gun manufacturers can and should be brought to the table to contribute ways to maximize safety. Thinking “outside the box” of state borders will be important to create sustainable reductions in youth mortality.

Clearly, we need more information and opportunities to determine the most effective ways to limit gun violence affecting children. Outcomes data cannot identify specific best practices. Research is needed to evaluate and report pilot programs. Those pilot programs need funding to try different approaches and keep track of their successes, limitations and challenges. The 1996 Congressional ban on research related to gun violence (under the guise of denying funds that “advocate or promote gun control”) severely hampered opportunities to identify best practices. That ban remained for over 20 years until Congress authorized $25 million to CDC and NIH in 2020. While this represented an important step in a better direction, it is insufficient to identify the best ways to preserve the lives of children.

Mortality from guns can be reduced with a commitment to recognize and prioritize this new leading cause of death among children. Identifying and adopting best practices will enhance dialogue and promote implementation of policies with proven efficacy. Increased funding and cooperation from all stakeholders are needed to develop new programs, implement them across communities and track their outcomes. Rather than a map of high and low mortality rates, collaborative approaches should be emphasized as a way to create a map in which pediatric deaths from gun violence are minimal across the country.