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Southern Medical Journal:
doi: 10.1097/SMJ.0b013e3181c9902e
Review Article

Do Guns Provide Safety? At What Cost?

Narang, Puneet MD; Paladugu, Anubha MD; Manda, Sainath Reddy MD; Smock, William MD; Gosnay, Cynthia RN; Lippmann, Steven MD

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From the Department of Psychiatry, Hennepin County Medical Center, Minneapolis, MN; and Departments of Psychiatry and Emergency Medicine, University of Louisville School of Medicine, Louisville, KY.

Please see the editorial “Guns and Safety” on page 103 of this issue.

Reprint requests to Steven Lippmann, MD, ACB Clinic, First Floor, 550 South Jackson Street, Louisville, KY 40202.

Accepted August 20, 2009.

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Many people feel that having a gun provides greater safety for them and their family. Actually, having a firearm in the home escalates the risk for death or injury, while using it to shoot someone who endangers the household is much less common. The resultant injuries, deaths, emotional turmoil, and/or disabilities lead to greater utilization of health care and legal/police services. Payment for these expenses is provided by higher insurance premiums and tax rates. This financial aspect has become a part of our country's current political concern over firearm ownership rights, gun violence or regulation, health care costs, the economy, and taxes.

Key Points

* The presence of a gun in the home results in more deaths to the owner and/or family members than to intruders.

* Suicide rates are escalated by firearm availability.

* Gun-related violence raises health care utilization and costs.

* Gun-related violence increases criminal justice system expenditures.

* Shootings result in higher costs to taxpayers and for insurance premiums.

* Gun-related violence leaves a legacy of grief and hardship.

Many Americans say, “I need a gun to protect my family and myself.” But does owning a firearm really provide safety? Does the prevalence of firearms in the United States have any association with the fact that our health care system is the most expensive in the world?

There is controversy about whether gun possession actually enhances personal safety. There is also discussion about the degree to which gun violence is a factor in increased medical expenses. Cutting health care costs is a current national agenda; less gun-related violence should result in some savings. With medical insurance, taxes, and the economy being active political issues, a review of firearm-related violence and its costs is relevant.

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Do Guns Provide Safety?

Gun use and regulations controlling them are important current issues. The Second Amendment to our Constitution states that, “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”; this remains a matter of active political debate. Some people think that this Amendment constitutes a citizen's right to gun ownership in America, while others believe that it does not guarantee easy firearm access to private individuals. Among some people there is a feeling that having a gun should diminish criminal activity since potential perpetrators are deterred from committing crimes when targeted victims may be armed. Others contend that they need weapons to protect themselves from the excesses of the government.

Access to guns affects the risk of death and firearm-related domestic violence.1,2 The presence of such weapons have been associated in America with high rates of suicide, accidental injury, homicide, and domestic violence.1 Suicide is the leading cause of death among gun owners in the initial years of acquisition.3 Out of 395 fatalities occurring at a family home where a gun was present, suicide accounted for 333 cases (84%); 41 were domestic violence homicides, and 12 were accidents, while only nine were shootings of an intruder.4 Presence of a firearm in the home reportedly results in death or injury to household members or visitors over 12 times more often than to an intruder.5 Trauma centers receive many people with gunshot wounds said to be “accidents,” but the circumstances in some of these cases seem to indicate that many of them initially were stress-related shootings, done originally with an intent to die.

Self-inflicted gunshot suicides outnumber both homicides and fatal accidents combined, and are the most common method of committing suicide.1 According to the Kentucky Violent Death Reporting System (http://www.kvdrs.uky.edu), there were 541 gun-violence deaths in Kentucky during 2005. Gun shot suicides accounted for 375 (69%), homicides for 143, accidents for 11, police shootings for 9, and 3 were undetermined. In Kentucky, suicide continued in 2006 and 2007 to occur over twice as frequently as homicide and all other shooting deaths combined. Household firearm ownership is associated with elevated rates of shooting oneself.6 This risk escalates not only for the owner, but also for suicides by family members or other people in the home.7 Many of these shootings are impulsive acts; pre-existing psychopathology is not a consistently present cause.8

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Do Guns Make Others Safe?

While there is a saying that, “guns don't kill, people do,” firearms are the most commonly used weapon in domestic homicides, accounting for about 65% of all such deaths.9 They increase the risk of intimate partner homicide by fivefold.10,11 Having a gun in the home results in loss of life to women by suicide three times more often than where no such weapon was available.11 In 2005, it was documented that 5,285 US children were killed by gunshots according to data collected over a full year time period by the Centers for Disease Control; compare this to none in Japan, 19 for Great Britain, 57 in Germany, 109 in France, and 153 in Canada.12 During 2002, the Children's Defense Fund with the National Center for Health Statistics reported that 3,012 American children were killed in shootings and many more were injured.12 Other sources agree, indicating that approximately 15 children or adolescents die from firearm-related causes every day in the United States.13 Although, Child Access Prevention laws exist, they are not uniformly enacted; the intent is to require parents to store firearms safely and deny access to children, while maintaining adult availability.14 Cases of domestic gun violence go beyond the actual event; as people who witness such tragedy exhibit higher levels of prolonged personal grief and dysfunction and higher suicidal risks than their peers.15

The consequences of gun-related violence, death, injury, disability, and/or dysfunction have a powerful impact on our society and health care system. Socially, it includes loss of loved ones, economic hardship, and psychological trauma to survivors. Bereavement compromises the quality of life after a shooting. This is especially true for children, even if they remain physically unharmed. Long-term adjustment problems often follow such traumas. When violent incidents occur in the community or if people generally feel threatened by consistent danger, it affects the whole population, thereby spreading the emotional pain. When young people repeatedly witness guns being used to deal with conflict, they adopt this form of problem solving. Medical expenses are affected as well, and this burden extends to the general population, governments, and the health care delivery system.

Guns have been utilized in assassinations of famous people, including several presidents. In America, guns are frequently used weapons in attacks on large numbers of people. The mass shooting at Virginia Tech in 2007 was initiated by a student who killed 32 individuals, wounded 24, and then committed suicide. This pattern of easy gun access, shooting others, and then oneself is tragically recurrent in our society. Easy access to firearms is well illustrated by the Virginia Tech incident. The shooter had a record which might not have passed the background check; according to the official report, he ordered his weapon over the internet and picked it up at a pawn shop.16 Beyond this, there are also fatalities during gang violence, criminal activities, drug procurements, interpersonal disagreements, law enforcement actions, or even random and accidental shootings. The sniper attacks in the Washington D.C. area during 2002 and the mass shootings of 2009 at Fort Hood, Texas are examples of the ongoing risk.

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What Is the Cost?

In 2005, approximately 30,000 Americans died of gunshots and nearly 70,000 received emergency treatment for nonfatal wounds.17 Emergency facilities are constantly burdened by the services required in such traumatic events. Medical care for these patients costs up to $4 billion per year.17 The overall economic cost due to these injuries in America, including healthcare, disability, unemployment, and other intangibles is about $100 billion per year.17

The case-to-fatality rate for gunshot trauma is 30%, which is much higher than for other injuries; for example, death occurs following a shooting 18 times more often than from motorcycle accidents.17 Typically, hospital stays for firearm-injured people are in the range of nearly two weeks' duration and disability averages approximately half a year.17 At a major Kentucky trauma center, medical care for gunshot victims in 2008 cost over $18 million, and charges for those needing admission averaged $43,000 per patient.18 In Louisville, Kentucky, expenses for the uninsured gun-injury victims alone exceeded the allotment of moneys allocated for all indigent care medical costs for the entire community. Similar concerns occur throughout our country. Death has a lower monetary impact. Disabilities, secondary illness, grief, and prolonged dysfunction add to the societal costs. Even these high numbers do not account for family losses and reduced social or personal productivity.

Taxpayers often bear a large percentage of these financial burdens; thus this matter is a hot political topic nationally. In Kentucky in 2008, 73% of gunshot victims were uninsured, 10% were covered by governmental plans, and 17% were insured.18 Nationally, data reported in 2001 documented that government programs pay for about 49% of this amount, 18% is covered by private insurance, and 33% by all other sources.19 Past medical bills are reflected in future insurance rates.2

Gun violence costs about 2.4 billion dollars annually to the criminal justice system in America, which is almost equal to all other crimes put together.19 Each homicide results in approximately $244,000 of incarceration expenses for our taxpayers. Indirect costs are high as well; for example, local governments across our country spend up to $100 million each year just on bulletproof vests.19 Most of these bills are then passed on to the taxpayers.

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Guns, purchased for protection, paradoxically result in increased rates of injury or death to the owners and their families. Since firearm possession is related to a high occurrence of domestic violence, restriction of access is sometimes suggested as a prevention policy. That, however, remains politically sensitive despite public wishes to reduce the costs of medical care and insurance. Availability tends to increase crime rates and the presence of these dangerous weapons escalates rates of both morbidity and mortality. Shootings are often precipitated during the commission of other crimes.9 Clearly, guns are easily available to the at-risk population; yet gun control remains generally unpopular. Firearm possession does not appear to yield safety. Documentation evidences that the presence of guns and injuries are correlated,17 and are thus related to medical attention and disability costs.

Gunshot injury, secondary dysfunction, or death is a common, but unintended consequence of firearm presence. It is generally accepted that American health care system expenditures are significantly higher than in other developed countries.20 Criminal justice system costs and incarceration expenses are similarly inflated. In spite of our medical system being so expensive and an active area of political and economic concern, firearms remain so much a part of our culture that gun-related violence and legal expenses are all routinely accepted as a normal part of our life.

Politically, gun control remains unpopular, but raising awareness among doctors about the relationship between firearms, the rates of violence, and expenses involved may have an impact on their thinking. Physician leaders in the community can have a legislative influence on gun safety. Even a small step could result in national benefit. We, as Americans, are in control of our political directions. Thus, we should decide whether this social and economic burden is one which we wish to continue to bear in the future or if some re-evaluation of gun regulation within our constitutional Second Amendment rights ought to be considered.

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1.Centers for Disease Control and Prevention; National Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS) [online]. (2006) [cited February 8, 2006]. Available at: www.cdc.gov/ncipc/wisqars. Accessed July 24, 2009.

2.Lemaire J. The cost of firearm deaths in the United States: reduced life expectency and increased insurance costs. J Risk Insur 2005;72:359–374.

3.Miller M, Hemenway D. Guns and suicide in the United States. N Engl J Med 2008;359:989–991.

4.Kellermann A. Guns for safety? Dream on Scalia. The Washington Post. June 29, 2008. Page B02. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2008/06/27/AR2008062702864.html. Accessed July 24, 2009.

5.Kellermann A, Heron S. Firearms and family violence. Emerg Med Clin North Am 1999;17:699–716.

6.Miller M, Lippmann S, Azrael D, et al. Household firearm ownership and rates of suicide across the 50 United States. J Trauma 2007;62:1029–1035.

7.Wintemute J. Guns, fear, the constitution, and the public health. N Engl J Med 2008;358:1421–1424.

8.Miller M, Barber C, Azrael D, et al. Recent psychopathology, suicidal thoughts and suicide attempts in households with and without firearms: findings from the National Comorbidity Study Replication. Inj Prev 2009;15:183–187.

9.Karch D, Lubell K, Friday J, et al. Surveillance for violent death reporting system, 16 states, 2005. MMWR (mortality and morbidity weekly report): surveillance summaries. April 11, 2008;57(SS03):1–43, 45. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5703a1.htm. Accessed July 23, 2009.

10.Campbell J, Webster D, Koziol-McLain J, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health 2003;93:1089–1097.

11.Bailey J, Kellermann A, Somes G, et al. Risk factors for violent death of women in the home. Arch Intern Med 1997;157:777–782.

13.Powell E, Sheehan K, Christoffel K. Firearm violence among youth: public health strategies for prevention. Ann Emerg Med 1996;28:204–212.

14.McClurg A. Child access prevention laws: a common sense approach to gun control. Presented at the St. Louis University Public Law Review Gun Control Symposium, St. Louis University, Missouri, 1999, pp 47.

15.Jouriles E, McDonald R, Norwood W, et al. Knives, guns, and interparent violence: relations with child behavior problems. J Fam Psychol 1998;12:178–194.

16.Giduck J, Chi W; Archangel Group, Ltd. An Evaluation and Assessment of the Law Enforcement Tactical Response to the Virginia Tech University Shootings of Monday, April 16, 2007. Colorado: Archangel Group 2008.

17.Cook P, Lawrence B, Ludwig J, et al. The medical costs of gunshot injuries in the United States. JAMA 1999;282:447–454.

18.University of Louisville School of Medicine. Gun Shot Wound Registry. Louisville, Kentucky, Department of Emergency Medicine, University of Louisville School of Medicine, 2008.

19.Cook P, Ludwig J. Gun violence: the real costs. JAMA 2001;286:605–607.

20.Davis K. Slowing the growth of health care costs—learning from international experience. N Engl J Med 2008;359:1751–1755.

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criminal justice system expenses; guns; health care costs; homicide; suicide

© 2010 Southern Medical Association


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