Firearms and Public Health in the United States

David Hemenway, Ph.D

New England Journal of Medicine

I have added things I know of to this article. I have an aversion to the word gun or guns by themselves. So get used to it if you expect to comment on this issue. Firearms are killing tools. If you shoot targets like I did pre-USMC, you get really good at staying in the black at various distances.

This is a good article. It keeps the tragedy of the Columbine Massacre front and center. It should not be forgotten.

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On April 20, 1999, in Colorado, two high school students shot and killed 12 of their fellow students and a teacher. At the time, it was the deadliest school shooting in U.S. history. What has happened in the quarter-century since then?

In part to reduce possible tort liability, Smith and Wesson took action. During the first year after the Columbine massacre, the most constructive response was Smith and Wesson agreeing to upgrade its products and practices to help reduce the harm caused by its firearms.

Since a common cause of unintentional shootings is incorrectly believing the firearm is unloaded. Its pistols would have chamber load indicators, and magazine disconnects would be available. The company would also provide “ballistic fingerprints” on new firearms helping law-enforcement agencies trace them. It would sell its firearms only to dealers who had a plan for preventing their theft, help to reduce trafficking, and agree to limit multiple-handgun sales to any individual buyer. The dealers would also have to agree not to sell large-capacity magazines.¹ But the firearm industry immediately began boycotting the company, and its chief executive officer was forced to retire.

Since then, the level of household firearm ownership in the United States has increased, federal firearm laws have been weakened, and the composition of the firearm stock has changed. Whereas most firearms owned in 1999 were long guns often obtained for hunting. Most new firearm are now handguns, and many of them are military weapons. The factors of high household firearm-ownership levels, the prevalence of handguns, the availability of military weapons, and weak firearm laws are strongly associated with high rates of suicide, homicide, and mass shootings.^2,3

In 2004, the federal assault-weapons ban that passed 10 years earlier was allowed to expire.

The federal ban on assault weapons and large-capacity (>10 rounds) ammunition magazines of 1994 had exemptions and loopholes that limited its short-term effects, but its expiration in 2004 was followed by an increase in the use of these weapons in mass shootings and other crimes. Growing evidence suggests that state-level restrictions on large-capacity magazines reduce mass shootings, but further research is needed on the implementation and effects of these laws.⁴

The implementation of U.S. federal and state assault-weapons bans affecting access to large-capacity magazines has been associated with lower rates of mass shootings and fewer deaths per shooting.⁴

In 2005, Congress passed the Protection of Lawful Commerce in Arms Act (PLCAA), which gave the firearms industry unusual protections from tort lawsuits. By limiting industry accountability for negligence, the law had a chilling effect on litigation. The impact of which was reducing any incentive liability laws might have given the firearm industry to help minimize the harms done by their products.

Americans should therefore not be surprised our firearm problem has worsened. The annual number of firearm deaths in the United States increased substantially between 1999 and 2021 (the most recent year with reliable data) from 28,874 to 48,830. The firearm homicide rate rose by 70%. The firearm suicide rate also increased by 33%. By 2021, more than 80% of homicides involved the use of firearms, as did 55% of suicides. The number of public mass shootings and school shootings increased markedly.

The future holds additional challenges for public health. “Ghost firearms” (do-it-yourself firearms), including 3D-printed firearms, are increasingly being found at crime scenes. These firearms rarely have serial numbers or require a background check to assemble.

Most important, the U.S. Supreme Court’s new interpretations of the Second Amendment make strengthening firearm laws more difficult. In the 5–4 Heller decision in 2008, the Court ruled, for the first time, that the Second Amendment was not about the militia (“A well-regulated Militia, being necessary to the security of a free State”) but about individual self-defense in the home.

In Heller⁵ Scalia wrote:

“Like most rights, the right secured by the Second Amendment right is not unlimited…. [It is] not a right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose.”

 In Heller, Scalia went on to specify several types of Constitutionally permissible restrictions: “For example, concealed weapons prohibitions have been upheld under the [Second] Amendment [and there is no] doubt on longstanding prohibitions on the possession of firearms by felons and the mentally ill, or laws forbidding the carrying of firearms in sensitive places such as schools and government buildings, or laws imposing conditions and qualifications on the commercial sale of arms.”

The purpose of the right, Scalia wrote, is for the protection of the home but “of course the right was not unlimited,” and it does not “protect the right of citizens to carry arms for any sort of confrontation.”

In 2022, the Court’s 6–3 Bruen decision created a new framework for evaluating challenges to firearm laws based on the Second Amendment. Although constitutional rights are commonly subject to balancing tests (weighing, for example, individual rights against public safety), the protection of the right to bear arms is subject to balancing only if the firearm law in question is first shown to be consistent with the nation’s “historical tradition of firearm regulation.” Supreme Court decisions that further weaken firearm laws are foreseeable.

Fortunately, there is some reason for hope. Better data are now available, and firearms research is expanding. The National Violent Death Reporting System (NVDRS) provides accurate information about the circumstances of all firearm deaths. Patterned on the motor vehicle fatality system, which provided the underpinnings for great advances in traffic safety, the NVDRS went from a dream in 1998 to a full-fledged surveillance system in 2020. It will continue to provide data for scientific studies about firearms.

The federal government, three states, medical care institutions, and more foundations have started to put some real money into the research effort. Evidence is accumulating on the large individual and societal costs associated with household firearm ownership. It exposes the reality of weaker firearm laws make us all less safe. Research convinced suicide experts, the U.S. Army, and the Veterans Administration, easy access to a firearm during high-risk periods increases the likelihood of suicide. Studies find that stronger firearm laws and requiring background checks at the point of purchase, can reduce interpersonal firearm violence. While laws loosening restrictions on firearm carrying and use (e.g., stand-your-ground and shall-issue carry laws) increase firearm homicide rates.⁵

Perhaps the most beneficial change has been the increasing acceptance of the public health approach to reducing firearm violence. This harm-reduction approach focuses on prevention rather than blame. It broadens the type of institutions that should be encouraged to act and the types of actions that any institution can take.

For example, there are Black barbers in the United States are working to reduce anger and depression among their clientele. We have hospitals investing resources in violence-prevention programs aimed at keeping people who have been shot from going back on the street to be shot again or to shoot someone else.

Public health experts are working with firearm trainers to develop voluntary ways to temporarily keep firearms out of the hands of people who become at risk for suicide.

At a local level, police chiefs now understand effective law enforcement should include direct prevention as well as arrests and punishment. They are trying to find better ways to work with their communities. Cities have violence intervenors who are helping to keep the peace among rival gangs. The federal government has established the White House Office of Firearm Violence Prevention, which can suggest, facilitate, and help coordinate and implement violence-prevention activities. This small, new office has the flexibility to be truly innovative.

Much more can be done and there are a myriad possibilities that could be done. The Surgeon General could provide biannual reports on firearms and suicide. The federal government could both conduct and fund research into smart firearms and safer means of home protection than owning a handgun. The police could have social workers embedded in precincts. The faith community could make it clear that it is a cardinal sin to sell a firearm to a stranger without a background check.

Most importantly our country could elect more officials who will help make changes where the effect will be greatest — in the firearm industry and the firearm culture. To achieve a huge reduction in firearm deaths will probably require mandating what is common for car drivers in the United States and for firearm owners in other high-income countries: firearm licensing, firearm training, and handgun registration, along with universal background checks. These requirements are supported by most Americans. PLCAA protections should be eliminated, and the firearm industry treated like other industries. The car manufacturers were forced to put seat belts, airbags, collapsible steering columns, and safety glass into their vehicles. The firearm industry should be forced to take the types of steps Smith and Wesson was willing to take.

I believe that the best way to honor past victims of firearm violence is to prevent future deaths.

Remember, if you fire a firearm, you own the bullet and no matter where it goes.

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1. Office of the Press Secretary. Clinton administration reaches historic agreement with Smith and Wesson. Clinton White House Archives, March 17, 2000

2. Studdert DM, Zhang Y, Swanson SA, et al. Handgun ownership and suicide in California. N Engl J Med 2020;382:2220-2229. PubMed

3. Stroebe W. Firearm possession and violent death: a critical review. Aggress Violent Behav 2013;18:709-721. Google Scholar

4. Koper CS. Assessing the potential to reduce deaths and injuries from mass shootings through restrictions on assault weapons and other high-capacity firearms. Criminol Public Pol 2020;19:147-170.

5. “The right to a firearm is not absolute.” Justice Scalia agreed. (statesman.com)