Can Public Policy Reduce Firearm Related Death in the United States?

Frederick H. Millham



The United States suffers from higher firearm related injury and death rates than any other developed country. Current public policy, informed by a permissive interpretation of the Second Amendment to the US Constitution, has resulted in three separate epidemics of gun violence: an epidemic of suicide, an epidemic of homicide and an epidemic of mass killings, the latter exemplified by the recent mass murder in Las Vegas. Each of these epidemics has different drivers and at-risk populations. However, it is the access to firearms and the characteristics of those firearms which drive each of these epidemics. More restrictive regulation of firearm, particularly handgun, access might reduce the suicide epidemic; however, absent a constitutional amendment, it may not be possible to meaningfully reduce gun related homicide in the United States.


Compared to other developed countries, the United States has significantly greater morbidity and mortality related to firearms.1 The Second Amendment of the United States Constitution records, in its entirety: “A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” These 27 words authored by James Madison over 200 years ago represent the most debated sentence in US history. Some interpret it to mean US citizens should have unfetter access to firearms. Others see the Second Amendment as permitting the regulation of private ownership of firearms. The recent massacre in Las Vegas, where over 600 people were shot, 58 fatally, has focused our attention on firearm related injury and spurred discussion on public policy solutions. In this paper I intend to outline the dimensions of firearm related death in the United States with hope of informing productive public policy discussion.

According to the most recent data available from the CDC, 36,252 people died as a result of gunshot wounds in 2015. Roughly 60% of these were suicides.2 Only 46 of these deaths were the result of mass-shootings involving three or more victims.3 Deaths due to mass shootings have roughly doubled over the past two years, but still represent less than 1% of the total lives lost to firearm injury. This epidemic of firearm related death in the US is in fact three epidemics, one of suicides, a second epidemic of homicides and within the homicide epidemic a third series of appalling mass killings.

Firearm suicides represent, by 2:1, the largest number of lives lost to firearms. Epidemiologically, firearm suicide is a disease of men, particularly white men. The rate of firearm suicide in white men rises through adulthood, peaking after the age of 70.4 Failure is exceedingly rare in firearm suicide. The latency from decision to act to suicide completion is instantaneous. There are no rescues. Therefore, immediate access to firearms is an important factor in the firearm suicide epidemic. In fact there is a significant relationship between rates of firearm ownership and of firearm suicide. A gun in the home increases the odds of a firearm suicide in that home by as much as 3-fold.5 Work that Turner Osler and I are currently conducting suggests that states with more restrictive laws, such as the requirement for a permit to purchase, have stable firearm suicide rates of around 4/100,000 people per year, whereas states with permissive firearms laws have twice this rate, and have seen rates increase by nearly 2/100,000 over the past seven years. Gun ownership confers on gun owners and those who live with them a significantly higher risk of gun suicide.

Firearm homicides have a different epidemiology. Firearm homicides are significantly biased toward men, but peak at a much younger age, between 20 and 24. African American men are dramatically over-represented among victims.4 Interestingly rates of gun ownership do not seem to be relat4d to firearm homicide rates. Rather, it is poverty rate and unemployment rate which, at least in state level data, are associated with firearm homicide rates.

Statistics from the FBI indicate that approximately three quarters of all US homicides are committed with firearms. Further, of firearm homicides, approximately three quarters are committed with hand guns. The use of high capacity, high velocity, semi-automatic long-arms often referred to as “assault weapons” (the firearm industry has rebrand these weapons as “modern sporting arms”) is unusual in shootings with fewer than three victims. Since the so called “Brady Bill”, which limited access to assault weapons, was allowed by Congress to expire in 2004 there have been 51 shootings with five or more victims recorded by Mother Jones mass-shooting da3abase.3 There appear to be no socio-economic, racial or gender factors which increase the risk of victimization in mass shooting. The firearms used in these events often differ from simple murders and assaults: 18 of 51 (35%) featured the use of at least one assault weapon. In these 51 events, a median number of total victims of 12.5 resulted when an assault weapon was used, compared to a median of 10 for others. As illustrated by the Virginia Tech massacre, where 32 people were killed by an assailant armed with handguns, mass murder is possible without assault weapons. Rather it is the semi-automatic loading and firing feature that is common to all of the automatic pistols and the assault weapons used in these attacks. The recent shooting of over 600 people in Las Vegas may be unique as the only mass shooting which, due to the extreme range from shooter to victim, could only have been carried out with an assault weapon. Policies which seek to reduce the incidence of high-casualty events due to firearms should therefore focus on the semi-automatic loading and firing feature shared by assault weapons and high-capacity semi-automatic hand guns.

Perhaps the greatest opportunity to reduce firearm related death is in suicide reduction. Were all states to require a government issued permit or other check on firearms access, or were weapons required to be stored under lock and key, there is reason to believe that firearm related suicides might be reduced. Absent significant restriction of access to handguns, and efforts to reduce poverty and unemployment, there is little hope of reducing firearm homicide. Assault weapons are more frequently used in mass shootings, but aside from the most recent attack in Las Vegas, assault weapons do not appear to be more lethal than semi-automatic hand guns. Moreover, firearms do not have a use-by date; they remain operational and effective for decades with minimal maintenance. There are over 300 million firearms currently in circulation. As long as the Second Amendment is interpreted to mean that Americans should have access to high-capacity, semi-automatic weapons, and high rates of gun ownership persist, there will be murders and mass-killings. Public policy alone cannot reduce firearm related death in the United States; it will require a Constitutional Amendment.

About the Author

Frederick Millham is a trauma and acute care surgeon. His research interests are in management of surgical emergencies, shock and surgical history. For the past eight fall semesters he has taught a Harvard Freshman Seminar entitled “A Brief History of Surgery”.


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