America’s home crisis: imagining communities where kids do not carry guns

Although recent statistics suggest a downward trend in homicide rates in major US cities, gun-related deaths remain a formidable menace in this country.¹ In no demographic is this more troubling than children. Firearm injuries are the leading cause of death among children in the USA.² These victims among our nation’s most vulnerable serve to, in the words of Martin Luther King Jr., “remind America of the fierce urgency of Now.”³

In their retrospective analysis of pediatric gun-related deaths in Tennessee, Strode, Lavvorn, and colleagues use data from the state medical examiner (ME) to characterize trends in mortality between 2012 and 2017.⁴ Using the Child Opportunity Index as an indicator of socioeconomic exposures, they evaluate the relationship between sociodemographics and risk of mortality. Their findings, although not surprising, are nonetheless alarming: firearm-related deaths increased over time, homicide rates increased most of all, and children from low-opportunity neighborhoods were at greatest risk of death by homicide. Suicide by firearm also increased over time.

The advantage of using ME data is demonstrated by the fact that almost half the patients were referred directly to the ME and therefore would have been missed in a hospital-based approach. Another strength of the study is the use of geocoding and Child Opportunity Index to characterize at-risk neighborhoods with precision, thus identifying communities where intervention may be most impactful. Unfortunately, as in comparable studies characterizing pediatric firearm injury, the elephant in the room remains: for all our descriptive statistics, we have not discovered a solution to the problem. The authors suggest that curbing access to firearms through legislation may be part of the solution. Other interventions proposed by Lee, Hoffman, and colleagues include safe gun storage initiatives, providing screening and anticipatory guidance in the primary care and emergency department settings, and multidisciplinary community-based programs.⁵ Although this study adds new data to a growing body of literature on pediatric gun violence risk stratification, it stops short of trialing an intervention to mitigate the risk it describes.^{6 7}

What I find most compelling in this article is the unmistakable connection between the nature of a child’s community and a child’s risk of harm. As New York Times columnist David Brooks observes, “America has a home crisis. When people do not believe they have a secure emotional, physical, and spiritual home, they become… cynical, anxious, and aggressive.”⁸ The interventions that will be most effective are those that transform communities into secure, inclusive, and nurturing spaces where guns have no utility.