EPIDEMIOLOGY OF GUN VIOLENCE As a public health

EPIDEMIOLOGY OF GUN VIOLENCE “As a public health community, we have tackled the opposition from the tobacco, asbestos and automotive industries and their political lobbying. We have reversed the tide of economic dependence that legislators and entire nations have had on these industries. It took time and determination but we made enormous progress. Reducing gun violence throughout the world will do wonders. We need to muster the same courage now as we did when we picked other low-hanging fruits of public health. ” --Dr. Eduardo Franco, Editor-in Chief of PM Professor at Mc. Gill University http: //www. journals. elsevier. com/preventive-medicine https: //www. elsevier. com/connect/gun-violence-experts-explore-critical-issues-from-multiple-angles

THE EPIDEMIOLOGY OF GUN VIOLENCE Jim Hart, MD, MBA Beth Commers, MEd. , Ed. S May 25, 2016

DISCUSSION POINTS 1. How people die 2. Guns: injury, homicide & suicide 3. Applying a public health model to reduce gun violence

THE RIPPLES OF GUN VIOLENCE At approximately 4 pm on April 7 th, 2016, Chase Passauer, a 23 -year-old clerk at North Star Criminal Defense Law Firm in the Dakotah Building was murdered.

10 LEADING CAUSES OF DEATH, MINNESOTA 2014, ALL RACES, BOTH SEXES

LEADING MECHANISMS OF INJURY MORTALITY MINNESOTA, 2004 -2013 (PROJECTED TO 2020)

MINNESOTA FIREARM MORTALITY 1%1% 1% 16% 80% Unintentional N = 1, 947 Suicide Homicide Undetermined Legal Intervention All Intents, 2004 -2013, by county All Intents, 2010 -2014

UNDERLYING CAUSE OF DEATH, 1999 -2014 FIREARM DEATHS, BY INTENT, MINNESOTA 35% Increase 1999 -2014 Suicide Homicide 9% Increase 1999 -2014

GUN VIOLENCE IN MINNESOTA: BEYOND THE HEADLINES FROM DR. STEVEN MILES # of Homicide Victims # of homicide victims %% of Population of pop 90 80 70 60 50 % 40 30 20 10 0 Blacks Whites CDC data http: //minnesota. publicradio. org/features/2013/04/gundeaths/index. shtml

RELATIONSHIP BETWEEN GUNS IN THE HOME & DEATH 2007 -2010 DATA, JAMA http: //archinte. jamanetwork. com/article. aspx? articleid=1661390

DATA 645 1565 7% 12. 6 86% 89% 80% 85% 52 50% 91 -52% 38% 59% 168 7 X 25. 2 x 49 x 8 x 6. 2 x 90% 91% 92% 82%

PUBLIC HEALTH MODEL FROM DR. CASSANDRA CRIFASI, JOHNS HOPKINS CENTER FOR GUN POLICY 1. 2. 3. 4. 5. Consider ALL deaths: homicide, suicide, unintentional injuries for ALL victims; Focus on prevention rather than punishment; Design, implement, and evaluate interventions; Consider the role of the “vector with violence as a contagion” and Take a multi-faceted approach that considers ALL determinants of violence: behavior change, law/policy, product/environmental change • • Societal: distribution of opportunity, income, social structure Community: population density, racial segregation Individual: temperament, cognitive abilities, drug/alcohol use Situational: availability of lethal weapons, presence of bystanders.

REDUCING GUN VIOLENCE WITH A PUBLIC HEALTH APPROACH Consider ALL deaths: homicide, suicide, unintentional injuries for ALL victims; 1. • Shift the culture war to a conversation on safety & public health • • • Responsible gun ownership & the 2 nd Amend go hand-in-hand Cars vs. guns Acknowledge suicide as gun violence • • Lethality of guns: 85% result in death vs 2 -3% of overdoses 65% of all gun deaths in America are suicide: MN = 80%+ 90% of people who survive a suicide attempt do not go on to die by suicide Allows us to discuss access

SUICIDE ü There are real actions we can take to dramatically reduce the number of gun suicides in our nation. ü One of the most significant things we can do is to stop making it so easy for so many people to take their own lives. ü This means not just thinking about the why people take their own lives, but also thinking about the way, which far too often is easy access to a gun. http: //www. bradycampaign. org/sites/default/files/Truth-About-Suicide-Guns. pdf

TEEN SUICIDE: ACCESS ü ü ü ü ü 3 rd leading cause of death for both ages 10 -14 & ages 15 -24. 82% of those age 17 & younger used a firearm belonging to a family member, usually a parent & 9% were guns they owned given to them by family (NVISS). Among the cases in which a youth used a family member’s gun, 75% included info about how the gun was stored—of which 64% were stored unlocked. 80% of teen suicides are at home. A home with a handgun is 4 -5 x more likely to have a teen suicide. Teen gun suicide attempts are 80 -90% lethal; 1 in 3 experienced a crisis that day (NVISS). NVISS study: only 4% had alcohol in system and 9% had opiates; . CDC: rate of teen suicide by firearm is increasing (only demographic with another Dr. Steven Miles: Suicide & Life-Threatening Behav. 2010; 40: 609 -11. Suicide and Life Threatening Behav. 2004; 34: 36 -43. http: //www. cdc. gov/violenceprevention/pdf/suicide-datasheet-a. pdf. http : //archinte. jamanetwork. com/article. aspx? articleid=1661390. means higher). Youth Suicide by Firearms Task Force. http: // www. pbs. org/thesilentepidemic/riskfactors/guns. html. http: //www. sprc. org/sites/sprc. org/files/library/Youth. Suicide. Fact. Sheet. pdf.

SUICIDE AFTER GUN PURCHASE 400 • Miles: Suicide leading cause of death of handgun buyer during 1 st year after purchase. • Crifasi: Connecticut vs Missouri: CT: -15. 4% reduction vs MO +16. 1% suicide by gun after PTP. All other suicide rates stayed the same. 350 300 Death / 250 100, 000 pyrs 200 150 100 Baseline Suicide Risk 50 0 1 2 3 4 5 6 7 8 9 10 Months after Purchase (Dr. Steven Miles) N Engl J Med 1999; 341: 1583 -9. http: //www. bradycampaign. org/the-truth-about-suicide-guns http: //www. jhsph. edu/news-releases/2015/suicide-by-firearm-rates-shift-in-two-states-after-changes-in-state-gun-laws. html

REDUCING GUN VIOLENCE WITH A PUBLIC HEALTH APPROACH 2. Focus on prevention rather than punishment Resist the temptation to see/talk about gun violence through a criminal justice lens • • Urban vs. rural argument Check your language • • • Gun control vs. gun safety UBC vs. CBC Closing the loopholes on gun sales and require CBCs on all purchases Expanding or reforming vs. ensuring , standardizing, and fair process

REDUCING GUN VIOLENCE WITH A PUBLIC HEALTH APPROACH 3. Design, implement, and evaluate interventions • Engage other health leaders, parents, educators, law enforcement & faith-based leaders • Ramsey County Public Health & RCAO • Patient Histories • Lethality Assessment: 58 % don’t ask their patients about firearms, even though 86 % believe firearm injury is a public health issue. • Moms Demand Action For Gun Sense & Be. Smartfor. Kids. org: unintentional death prevention • Recognize risks of teen suicide and unlocked guns at home http: //www. ncbi. nlm. nih. gov/pubmed/24722784

REDUCING GUN VIOLENCE WITH A PUBLIC HEALTH APPROACH 4. Consider the role of the “vector with violence as a contagion” • Cure Violence Approach 1. Detect and interrupt potentially violent conflicts 2. Identify and treat highest risk 3. Mobilize the community to change norms

REDUCING GUN VIOLENCE WITH A PUBLIC HEALTH APPROACH 5. Take a multi-faceted approach that considers ALL determinants of violence: behavior change, law/policy, product/environmental change • Lawmakers: A higher number of firearm laws in a state are associated with a lower rate of firearm fatalities in the state, overall and for suicides and homicides (AMA, 2013. ) • Firearms fatalities stable over last 10 years • 2005: medical costs of firearms: • Fatal injuries $112 million; non-fatal injuries at $599 million • Work loss estimated at $40. 5 billion • Firearm fatality rates: • Low law states vs. high law states Firearm Legislation and Firearm-Related Fatalities in the United States. Eric W. Fleegler, MD, MPH; Lois K. Lee, MD, MPH; Michael C. Monuteaux, Sc. D; David Hemenway, Ph. D; Rebekah Mannix, MD, MPH, May 13, 2013. http: //archinte. jamanetwork. com/article. aspx? articleid=1661390

THE RELATIONSHIP BETWEEN GUN LAWS, OWNERSHIP &DEATHS Firearm fatalities Per 100, 000 Louisiana = 17. 9 vs. Hawaii = 2. 9 http: //archinte. jamanetwork. com/article. aspx? articleid=1661390

REDUCING GUN VIOLENCE WITH A PUBLIC HEALTH APPROACH � Require background checks on all gun sales to keep guns out of the hands of dangerous people and saves lives. • • 60/40 airport screening 18 states and Washington, DC go beyond federal law and require background checks on all handgun sales. 6 since Sandy Hook. People in these states make up 48. 8% of the US population In states that require checks: • 46% fewer women are shot to death by intimate partners. • 48% fewer law enforcement officers are killed with handguns. • 48% fewer people kill themselves with guns. • 64% fewer illegally trafficked guns. • 17% fewer aggravated assaults with firearms occur. • After Missouri repealed BCs, 25% more firearm homicides and a 150% increase in the share of likely trafficked guns.

QUESTIONS? Dr. Jim Hart hartx 013@umn. edu Beth Commers 651/247 -7009 bethcommers@gmail. com