By: Mark H. Hoofnagle, MD, PhD, Trauma and Acute Care Surgeon Washington University School of Medicine Barnes-Jewish Hospital

This blog is part of a special series by the Harris Institute’s  Gun Violence and Human Rights Initiative and the Institute for Public Health’s Gun Violence Initiative in recognition of National Gun Violence Awareness Month, launched on June 5th for Gun Violence Awareness Day. Throughout this series we will highlight the work being done on this critical issue across campus, the St. Louis region, and the country.

Firearm violence in the United States is exceptional compared to anywhere else in the world, yearly costing taxpayers hundreds of billions of dollars equivalent to ~1% of GDP yearly, and claiming more lives in the last decade than we have lost in any war in our history.  Only late in the last century was firearm violence beginning to be recognized as a public health problem, and concurrently, of the role of structural violence and structural racism in its persistence and disproportionate effect on African Americans. 

Structural violence occurs when social structures themselves create, propagate and increase the frequency of injury, illness and death in a population. Structural racism is a form of structural violence that contributes to violence in populations along racial lines and serves to maintain long-standing racial inequalities.  There is a growing understanding among physicians of the role of structural violence in the health of our patients and in the public health problem of firearm violence.  

The American College of Surgeons (ACS) has repeatedly stated that firearm violence is a public health crisis and that structural violence is a risk factor for such violence. The consensus of 45 medical and injury prevention organizations, including surgical societies such as the ACS, and trauma surgical societies such as EAST and AAST, is that that a national public health approach to firearm violence is needed and wanting.

The enormous obstacle to implementing a public health solution that would help our patients is largely the unwillingness of all states to implement responsible gun legislation, resulting in a patchwork of state and local laws that do little to prevent the deaths of our patients.  According to an analysis from the University of Pennsylvania examining 462,000 firearm deaths, that while firearm homicides disproportionately affect African American men compared to white men, most firearm legislation to date has yielded little results in protecting this population. 

SOURCE: Universal background checks for handgun purchases can reduce homicide rates of African Americans, Journal of Trauma and Acute Care Surgery88(6):825-831, June 2020.

If anything, the last decade has seen a push for increasing laxity of firearms laws resulting in greater burdens of firearm homicide. For instance, a recent independent analysis of available evidence by the RAND Corporation found that states that have passed “Stand Your Ground” laws experience higher rates of violent crime and unjustified homicide.  Evidence is mounting that the recent expansion of laws loosening restrictions on possession and use of firearms, such as “shall-issue” conceal permit laws and “Stand Your Ground” laws, worsen homicide rates and  contribute to excess mortality in African Americans

The patchwork of state laws themselves create ample opportunity for trafficking of firearms for criminal use and a persistent pattern is observed of guns used in crime in states with responsible gun legislation, more frequently originate from out-of-state. There is a frequent refrain that “criminals don’t obey laws”, however, they clearly obey some laws as there is clearly an economic incentive to traffic firearms from areas of lax legislation suggesting restrictive firearm legislation does work – it is merely undermined by the legal patchwork.  Guns used in crime can almost always be traced to a “legal” purchase, suggesting it is actually the “lawful gun owners” that are ultimately arming the criminals in this country either through improper storage and subsequent theft, or direct sale into gray and black markets.  Indeed, a fascinating survey study of criminals in Baltimore describe their sources of firearms as originating largely from straw purchases, crooked Federal Firearms License holders and stolen firearms.  The financial benefit the firearms industry experiences from this trafficking is difficult to quantify, but at least one analysis suggested that illegal trafficking of firearms just across the US-Mexico border is responsible for between 0.9% and 3.7% of all domestic gun sales.  Guns are durable goods after all that, if maintained properly, can be handed down generation to generation.  Crime guns, on the other hand, are a short-term disposable good, and need to be replaced frequently. 

Network graph of firearm traces 2015–2017
SOURCE: Firearm laws and illegal firearm flow between US states, Journal of Trauma and Acute Care Surgery: June 2020 – Volume 88 – Issue 6, p 752-759

This current pattern of laws serves to increase violence and aggravate the deaths in populations vulnerable to gun violence and thus represents a persistent source of structural violence and racism.  We know from systematic review of the available data there is an association between more restrictive licensing and laws, background checks and lower firearm injury rates which could be expected, if made universal, to positively impact firearm violence and homicide in African Americans.  Indeed, careful “difference-in-difference” statistical analyses of firearm laws and their effects specifically on firearm homicide in African American men suggest universal background check laws (UBC) could reduce their homicide fatality rate by 19%.  Significant evidence is also building that laws being passed encouraging routine carry of firearms and escalation of conflict further worsens racial inequity and increase structural racism with African Americans in particular suffering the worst from our health and firearm policy.  A 2015 National Task Force on “Stand Your Ground” laws commissioned by the American Bar Association suggested these laws increased racial disparities in the criminal justice system. The laws were found to be unevenly applied by race with African Americans the disproportionate victims.

This is in addition to decades of structurally racist economic policy, such as historic redlining, which also  have been found to negatively impact firearm violence in African Americans with the greatest violence tracking with historic patterns of racist policy. Finally, racist attitudes themselves predict support for firearm policies that disproportionately harm African American men.  The evidence combined shows the historic and persistent application of racially biased laws that negatively affect African Americans prosperity and health results in the disproportionate violence in their community, and the unwillingness to change policies to protect them is at least partially motivated by overt racism.

Firearms, while privately purchased, have a significant and negative impact on the public health.  The firearm industry for years has promoted increasingly powerful and militaristic hardware for “home-defense”, suggesting that firearms have some role in individual protection or safety.  However, there is no evidence that firearms make us safer, and excessive evidence that firearms are far more frequently used to threaten, maim and kill than protect. For decades, we have known a firearm in the home increases the risk of both homicide and suicide and this observation has been durable. Systematic review of states with lax conceal carry are not found to have protective benefit on crime or homicide.  Those who carry a firearm concealed, rather than being less likely to die of homicide are 4-5 times more likely to die compared to their demographically matched cohorts – and their risk increased when they have the opportunity to use the firearm in their defense (lesson – de-escalating or fleeing generally safer than “standing your ground”). Pseudo-academics, with very questionable research methods, have supported the gun industry with grossly inflated figures of “defensive gun use”, however, subsequent analyses have discredited this defense of firearms as protection. Firearms are more often used to threaten others than defend.  The final nail in the coffin for “defensive gun use” is when gun owners recollections were analyzed independently by legal experts the majority of time they reported unlawful assaults and escalations of violence as “self-defense”.

This marketing strategy has, however, been remarkably successful in expanding the market for increasingly more dangerous firearms for individual ownership, and disturbingly, the more the customer believes the bizarre myth that “guns are safe” the more likely they are to store it unsafely in their home – loaded and unlocked where anyone can access it, steal it, or happen upon it.  According to this survey this is the overwhelming majority of gun owners, and less than 5% (like me) report correctly that guns are fundamentally unsafe and make your home less safe.  While motivations for owning a gun may fairly include hunting and sport, safety cannot conscionably be justified as a legitimate reason based upon the overwhelming literature on their detrimental effect on individual and societal safety.

From the best available data we can safely conclude that firearms serve no protective benefit, and worsen the public health.  Vulnerable populations and particularly African Americans suffer disproportionately from firearm homicide; the laws, both historically and presently, which maintain this disparity are structurally racist and serve only to reinforce racial inequality.  The role of industry, and profit, in maintaining this relationship is not fully clear, but there is mounting evidence that suggests they are motivated to protect the trafficking of firearms into black markets for their profit margins.  And the evidence is abundantly clear that their marketing of firearms for protection has no basis in reality and actively harms the health of their customers by making them more likely to engage in unsafe practices.

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