Gun Control Issues, Public Health, and Safety Gunshot wounds impact severely on the criminal justice as well as health care systems. Some basic statistics are important in understanding the magnitude and severity of the social and economic burden to the U.S. The subject remains contentious. (Glantz and Annas, 2009) Though the U.S. has about 4.5% of the world's population, The U.S. accounts for 45% of all civilian-owned guns worldwide. (Wintemute, 2015) In 2015 over 36,000 persons died from a firearm-related injury, and of these, 61% were suicides, 36% homicides, and 1% unintentional. Males were over 6 times more likely to die from a firearms injury. (CDC, 2017) The rates of firearms deaths in the U.S. vary by time, race, and sex. The U.S. national average was 10.2 deaths per 100,000 population from 2010-2012. The highest rate was 18.1/100,000 for African-Americans, almost double the rate of 9.8/100,000 for whites. Young adults age 25-34 have the highest rate (15.1/100,000). The suicide rate is highest among the elderly age 65 and over (10.9/100,000). Nearly half of all firearm deaths occurred in the South. (Fowler et al, 2015) Among adults, acute alcohol intoxication and a history of alcohol misuse are independent risk factors for firearm violence. (Wintemute, 2015) Firearms injuries account for a significant number of hospital visits. From 2010-2012 in the U.S., over 67,000 persons per year (21.6/100,000) received emergency medical treatment for a firearm-related injury, and over half of these required hospitalization. (Fowler et al, 2015) In one study the mean charges per person were $5254 U.S. for emergency department patients and $95,887 for inpatients, resulting in the annual financial burden estimated at $2.8 billion. (Iacobucci G, 2017) The rate of nonfatal firearms injuries has declined over the past 2 decades in the U.S. (Kalesan et al, 2013) Between 2010 and 2012, the combined lifetime medical and work loss costs were estimated at $48 billion. (Fowler et al, 2015) Child safety is an important issue. Firearm-related deaths are the third leading cause of death overall among U.S. children 1 to 17 years of age, surpassing the number of deaths from congenital diseases, heart disease, respiratory infections, and cerebrovascular diseases. Nearly 1300 children die and nearly 5800 are treated for gunshot wounds each year. The highest rates for pediatric homicide are in southern states. Of all firearm deaths in children up to 14 years of age living in high-income countries, 91% occur in the U.S. Childhood suicide risks involve acute crises and life stressors including relationship, school, and crime problems. (Fowler et al, 2017) Accidental child shooting deaths are most commonly associated with one or more children playing with a gun they found in the home. (Choi, et al, 1994) The person pulling the trigger is a friend, family member, or the victim. (Harruff, 1992) In the period from 1979 to 2000, accidental firearms deaths involving children declined in the U.S., aided by child access prevention laws and felony prosecution of offenders. (Hepburn et al, 2006) This trend has continued, as reported in a study from 2009 (Safavi et al, 2013). A study of nonnatural deaths in a large American city revealed that half of such deaths in persons from 10 to 19 years of age were due to homicide, and firearms were involved in 88% of them. (Heninger and Hanzlick, 2008) The table below indicates mode of death for firearms injuries in the ten countries with the most reported deaths from firearms for children less than 15 years of age. (CDC, 1997) Firearms Deaths by Mode of Death for Children <15 Years of Age Top 10 Countries - Rate per 100,000 In one survey, 10% of families admitted to having unlocked and loaded firearms within easy reach of children (Patterson and Smith, 1987). Another study showed that two-thirds of accidental firearms injuries occurred in the home, and one-third involved children under 15. 45% were self-inflicted, and 16% occurred when children were playing with guns. (Morrow and Hudson, 1986) A study from 1991-2000 showed that twice as many people died from unintentional firearm injuries in states in the U.S. where firearm owners were more likely to store their firearms loaded. (Miller, et al, 2005) A study of firearm deaths in high income countries (Australia, Austria, Canada, Czech Republic, Finland, France, Germany, Hungary, Iceland, Italy, Japan, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Slovakia, Spain, Sweden, United Kingdom (England and Wales), United Kingdom (Northern Ireland), United Kingdom (Scotland), and the United States) was conducted with data from the World Health Organization assembled by the WHO from the official national statistics of each individual country from 2003 (Richardson and Hemenway, 2011). The total population for the United States for 2003 was 290.8 million while the combined population for the other 22 countries was 563.5 million. There were 29,771 firearm deaths in the US and 7,653 firearm deaths in the 22 other countries. Of all the firearm deaths in these 23 high-income countries in 2003, 80% occurred in the US. In the US the overall firearm death rate was 10.2 per 100,000, the overall firearm homicide rate 4.1 per 100,000, and the overall homicide rate 6.0 per 100,000, with firearm homicide rates highest persons 15 to 24 years of age. For the US the overall suicide rate was 10.8 per 100,000, and slightly over half of these deaths were firearm suicide (5.8 per 100,000). Firearm suicides rates increased with age. In the other high income countries 2003 the overall firearm death rate was 1.4 per 100,000, the overall firearm homicide rate 0.2 per 100,000, and the overall homicide rate 0.9 per 100,000. Firearm homicide rates were highest in the 25 year old to 34 year old age group. The overal suicide rate was 14.9 per 100,000 with a overall firearm suicide rate of 1.0 per 100,000. A comparison across countries for an earlier time period is shown below. Firearms Death Rate (per 100,000, age adjusted) for Selected Countries in one year between 1990 and 1995 (Krug, Powell and Dahlberg, 1998)



The number of firearms injuries remains high in the United States, compared with most of the rest of the world. Firearm suicide rates are strongly impacted by the rate of gun ownership. (Kaplan and Geling, 1998) There is a positive correlation between firearm fatality rates and number of guns in developed nations. (Bangalore and Messerli, 2013) The number of firearms in the hands of private citizens in the U.S. far exceeds that of other countries. Thus, the laws of the U.S. Federal government as well as the states do not as yet severely restrict the manufacture, sale, and use of firearms by ordinary citizens. "Gun control" is a sensitive issue that evokes strong emotions in persons both for and against control. Politicians find it difficult to deal with this issue. There is disagreement as to whether a reduction in access to or numbers of firearms will have a measurable effect upon crime. The Brady Handgun Violence Prevention Act passed in 1994 in the U.S. established a nationwide requirement that licensed firearms dealers observe a waiting period and initiate a background check for handgun sales (but the law does not apply to secondary markets). Laws related to strenthening background checks and permit-to-purchase firearms appears to have decreased firearm homicide rates. (Lee et al, 2017) Attitudes and tolerances may be reflected in the high visibility of firearms and firearms-inflicted injuries that are portrayed in the media. (Price et al, 1992) One thing remains certain, despite laws for or against gun control, a lack of care and concern regarding one's fellow human beings, whether in war or through domestic violence, will continue to promote firearms injuries. The issue of "home defense" or protection against intruders or assailants may well be misrepresented. A study of 626 shootings in or around a residence in three U.S. cities revealed that, for every time a gun in the home was used in a self-defense or legally justifiable shooting, there were four unintentional shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides (Kellermann et al, 1998). Over 50% of all households in the U.S. admit to having firearms (Nelson et al, 1987). In another study, regardless of storage practice, type of gun, or number of firearms in the home, having a gun in the home was associated with an increased risk of firearm homicide and suicide in the home (Dahlberg, Ikeda and Kresnow, 2004). Persons who own a gun and who engage in abuse of intimate partners such as a spouse are more likely to use a gun to threaten their intimate partner. (Rothman et al, 2005). Individuals in possession of a gun at the time of an assault are 4.46 times more likely to be shot in the assault than persons not in possession (Branas et al, 2009). It would appear that, rather than being used for defense, most of these weapons inflict injuries on the owners and their families. Hunting accidents with firearms, despite the large gun ownership in the U.S. and numerous game seasons in most states, remain relatively rare and do not appear to be increasing. (Huiras, et al, 1990) In a study of accidental hunting firearm injuries and fatalities from 1961 to 1992 in Germany, there were 257 cases, most involving experienced hunters. 26% of the gunshot wounds were fatal. 23% of cases were self-inflicted and 77% injuries caused by another person. The firearms/ammunition included shotguns (63%) and shotgun slugs (3.5%), rifle bullets (31%), and handgun butllets (2.5%). 22% of pellet accidents produced severe eyeball injuries. 38% of the wounds occurred at a distance of 5 m or less, including all self-inflicted injuries. The most frequent factors responsible for the accident were: improper handling of the firearm (37%), failure to notice the victim (24.1%), covering the victim while swinging on the game (14.8%), ricocheting projectiles (13.6%), inadequate storage of the firearm (11.7%) and mistaking the victim for game (9.3%). (Karger et al, 1996)